MassHealth 101: An Integrative Perspective

Impacting the lives of Children & Families

Bethany Spheekas, Elizabeth Blumin & Jonna Green

Mission Statements of our Collaborators

Wheelock College: To improve the lives of children & families.  

Edward M. Kennedy Community Health Center:

Organizational Values – We believe that everyone has a right to accessible, high quality, comprehensive, integrated and compassionate healthcare.  

Participatory Action Research Group: The mission of this student research group is to

create education and awareness about human rights as it relates to disparities in healthcare.

Healthcare is a HUMAN RIGHT!

The Declaration of Human Rights  

Article 25 (1) “Everyone has the right to a standard of living

adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control”.

(2) advocates specifically for women and children, “Motherhood and childhood are entitled to special care and assistance. All children, whether born in or out of wedlock, shall enjoy the same social protection”

(Reichert, 2006, p. 177)

Healthcare is a HUMAN RIGHT!

Convention on the Rights of the Child  

Article 24 (1) “Parties recognize the right of the child to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health”

(Reichert, 2006, p. 246)

What is MassHealth?

MassHealth is a public health insurance program for eligible low and medium-income residents of Massachusetts. MassHealth is the name used in Massachusetts for Medicaid and the Children's Health Insurance Program (CHIP), combined in one program.

This change was part of the Massachusetts healthcare insurance reform law enacted in 2006, (informally referred as RomneyCare). Healthcare Reform requires every Massachusetts resident to have a minimum level of healthcare insurance coverage (even if their employer does not provide private health insurance).

MassHealth provides “free” healthcare insurance for residents earning less than 150% of the federal poverty level.

MassHealth (Medicaid) vs. Medicare

MassHealth (Medicaid)

MassHealth is a public need-based health insurance program.

MassHealth you must qualify under certain eligibility requirements determined by the state in order to receive it.

Medicare Medicare is operated by the

Social Security Administration (SSA) and pays for medical care for individuals with disabilities and individuals over the age of 65 who receive SSA benefits.

You do not have to be low income in order to be eligible for Medicare.

It is possible for an individual to receive both Medicare and MassHealth if they fall into the low-income bracket. MassHealth will cover all costs of Medicare policy premiums, deductibles and any medical bills that Medicare will not cover.

How is MassHealth funded?

MassHealth is a public health insurance program overseen by the Executive Office of Health and Human Services. The Federal government pays half of the cost of MassHealth and the state government pays for the remaining costs. 50% 50%

Who is MassHealth for?

Children Parents / caretakers

of children Adults working for

small employers Unemployed

individuals Pregnant women Individuals with

disabilities Department of Mental

Health (DMH) clients

HIV+ individuals Elderly people Women with breast or

cervical cancer People in need of long-

term care Non-Citizens* who meet

eligibility requirements for other social service programs (WIC, SNAP, etc…)

*limited coverage

Who is Eligible for MassHealth?

You Must: Match one of the categories mentioned Be a Massachusetts resident Meet the financial eligibility requirements

EXCEPTIONS to Need-Based Requirement include:

Anyone who receives TAFDC, SSI, or EAEDC benefits

Children eligible for foster care or adoption assistance

Young adults (18-21) who were still in DCF care on their 18th birthday

Refugees eligible for resettlement assistance

How can I check if my client is eligible for MassHealth?

Online Benefits Eligibility Check

*** This is NOT a guarantee of benefits

What happens next?

Eligibility determination typically takes 4-6 weeks after the application is submitted.

Typically no coverage is available during this period… however, some services may be retroactively reimbursed.

MassHealth will determine which plan you qualify for based upon your income and other eligibility criteria.

MassHealth Standard and CommonHealth offer the most benefits

MassHealth Limited only covers emergency health services

Benefits / Services Covered by MassHealth

Inpatient care at hospitals or other medical facilities

Outpatient care in MD offices, clinics, hospitals

Testing and medical equipment

Well-child services for children under 21

Inpatient/Outpatient Mental health & substance abuse treatment

Dental services (non-cosmetic)

Prescription coverage Tobacco cessation

services Home Health Care (HHC) Hospice services Adult day care Chiropractic services Early Intervention

Services Transportation services

(*to medical appointments only)

Mental Health and Substance Abuse Treatment Coverage

Programs that provide mental health and substance abuse treatment include:

MassHealth Standard MassHealth Basic CommonHealth MassHealth Family Assistance (Direct Care

and Premium coverage for HIV members) MassHealth Essential

*MassHealth Limited and Prenatal members are NOT covered for non-emergency mental health or

substance abuse treatment services

Mental Health Services for Children

Children’s Behavioral Health Initiative Services Include:

Behavioral Screenings /Assessement Outreach In-Home Therapy Services Intensive Care Coordination (ICC) Mobile Crisis Intervention ( i.e. BEST team) Family Support and Training Therapeutic Mentoring Services

* Parents do not need to be eligible for MassHealth themselves in order to be eligible for support services for their children

Additional Programs Available

* These are other public health programs under the MassHealth “umbrella”. They typically provide less coverage than MassHealth Standard, however the eligibility requirements are not as stringent. Most of these plans have monthly premiums.

Commonwealth Care (MCO)

Commonwealth Choice

TriCare

Insurance Partnership

Children’s Medical Security Plan (CMSP)

Health Safety Net (Free Care) *No Monthly Premium

OK… what does it cost?

Cost depends on the program you are enrolled in. MassHealth Standard has the lowest cost to

patient and no monthly premium or copayments (OV/Rx)

If you are at or below the 150% poverty level you do not have to pay a monthly premium regardless of plan

Monthly co-payments increase incrementally based on monthly income

All of these plans have minimal or no copayments for prescription coverage * depending on tier of Rx

Some plans have an annual deductible in addition to monthly premiums & copayments

Importance of Community Health Centers

Community health centers, introduced in 1965 by President Johnson, were initially designed to reduce or eliminate health care disparities that affected racial and ethnic minority groups, the poor, and the uninsured.

In light of recent policy changes in Massachusetts and other states, community health centers are a critical element of healthcare reform aimed at expanding access to healthcare for 20 million Americans, 5% of the current United States population receive primary care at these sites

(Adashi , Geiger & Fine, 2010)  

Disparities in Health Coverage and Access to Care Remain

Even since the introduction of this healthcare reform in Massachusetts ¼ of Massachusetts residents still find cost to be a preventative barrier to getting the healthcare they need. (Clark, 2011)

Data obtained via telephone between 2006-2008 suggested that there were improvements in access to care, but that reductions in out-of-pockets expenses were not sustained. Results indicate that overall trends show a significant improvement in healthcare coverage from 94.7% in 2006 to 97.7% in 2008 since the healthcare reform was initiated in Massachusetts. Although these percentages imply that the percentage of healthcare coverage was alarmingly high before the healthcare reform was initiated, it does at least show that since the healthcare reform, Massachusetts’ healthcare coverage has increased in the populace. (Zhu et al. 2010)

Improved access to Care for Massachusetts

with the exception of Hispanic Population

Although health insurance coverage has increased in Massachusetts since the passage of the health care mandate Hispanic families are covered at a much lower rate than non-Hispanics according to research conducted though phone-based outreach, focus groups and interviews. Language barriers may account for a major factor impacting health care coverage and is a major area for concern. Additionally, co-pays were identified as a common barrier to clients receiving care.

(Maxwell et. al 2011)

2012 Patient Population = 23,923

<1 yr

1-4

yrs

5-12

yrs

13-1

4 yr

s15

-19

yrs

20-2

4 yr

s25

-44

yrs

45-6

4 yr

s65

+ yrs

20%25%30%35%40%45%50%55%60%65%70%

57%

48% 52% 51% 49%

37% 38%42%

39%43%

52% 48% 49% 51%

63% 62%58%

61%

%Male by Age group %Female by Age group

Age Group

% U

sers

per

Gen

der

N = 23,923

Male43%Female

57%

Gender Ratio of Users FY2012

N = 23,923

•Patients are predominantly female; the skewed distribution is more pronounced after age 19

Racial Diversity within EMK-CHC Patient Population

White72%

Black or African American16% Multi-racial

6%Asian

3%Unknown/Unreported

3%

Hawaiian/Pacific Islander<1%

American Indian/Alaskan Native<1%

64% of those who identify as White are of Latin American/Caribbean origin; 23% are North Ameri-cans; 2% are Middle Eastern; and 11% identified as other ethnicities.

Latin American/Caribbean

56%

North American 21%

African 6%

Unknown9%

Middle Eastern 2%

Asian 3%

European 2%

Pacific Islander <1%

Cape Verdean <1%

Latin American/Caribbean Patient Population

Brazilian43%

Puerto Rican28%

Other Central American

11%

Dominican9%

Other South American

5%Mexican

3%Haitian

1%

Cuban<1%

Other Caribbean<1%

Ethnic Diversity of Whole Patient Population

Want to know what we found?

View our poster and attend our Integrative Presentation

Monday, May 6th

Hawes Campus

10 a.m. – 3 p.m.* Specific presentation time TBA

MassHealth Resources/Links

MassHealth Application

PT-1 Form (Transportation Service)

http://www.mass.gov/eohhs/gov/departments/masshealth/

http://www.massresources.org/masshealth.htm

http://www.massresources.org/masshealth-links.html

CBHI Info http://www.doe.mass.edu/tss/events/050409RosieD_wssk.pdf

Any Questions?