What is MassHealth CommonHealth and how can it help people with Autism?
MassHealth CommonHealth is a MassHealth program available to individuals with disabilities who are not eligible for MassHealth Standard. Unlike MassHealth Standard, MassHealth CommonHealth participants are not subject to income or asset limitations. MassHealth CommonHealth is an option for people with disabilities who have income that exceeds 133% of the federal poverty level (FPL). It allows individuals with disabilities to purchase health coverage through a sliding-scale monthly premium that is based on total household income.
For people who have private insurance coverage through their employer, MassHealth CommonHealth will pay for any medically necessary Medicaid-covered services that the employer health plan does not cover, including co-pays, co-insurance and deductibles, as long as the provider accepts MassHealth. The sole exception is ABA (Applied Behavior Analysis): the ABA provider does not have to be a MassHealth provider for co-pays to be covered.
In addition, people with MassHealth CommonHealth can obtain Premium Assistance, which may cover some, and sometimes all, of the cost of the premium/payroll deduction for the private insurance.
People under 21 with MassHealth CommonHealth may be eligible for additional home-based services through the Children’s Behavioral Health Initiative (CBHI). For more information, visit The Massachusetts Behavioral Health Partnership (MBHP).
The out-of-pocket expenses for MassHealth CommonHealth are:
- monthly premiums,
- prescription co-pays.
Monthly premiums vary based on household income, family size, whether the recipient has other insurance, and premium assistance benefits. The premium gradually increases with income, which includes wages, SSI/SSDI, and other cash benefits. For youths between 18 and 21 years old certain work requirements and a one-time deductible may apply.
Each family needs to evaluate the costs and benefits of adding MassHealth CommonHealth coverage. This decision should be based on various factors, including the amount of the MassHealth CommonHealth premium, the family’s out-of-pocket medical costs from private insurance that would be covered by MassHealth CommonHealth, the amount of Premium Assistance that may offset the CommonHealth premium, and how much you expect to use services covered by MassHealth CommonHealth. The AIRC can help families analyze whether CommonHealth will be cost-effective before they apply.
What services are available under MassHealth CommonHealth?
- Inpatient and outpatient hospital services
- Medical services including lab work, X-rays, therapies, and some dental services
- Applied Behavioral Analysis (ABA) /Social Skills (up to age 21)
- Children’s Behavioral Health Initiative (CBHI) Services
- Medical equipment, hearing aids, and prescription drug coverage
- Personal care assistant services
- Mental health and substance abuse services
- Medical-related transportation services
Do I have to keep my child on my primary insurance through work if they have Commonhealth?
Yes. MassHealth is the payor of last resort. This means that they require members to enroll in, and maintain, affordable employer sponsored insurance (ESI). (MassHealth will determine whether available ESI is affordable.) Note: you are required to use your primary plan first if it provides coverage for the services you need.
How does one apply for MassHealth CommonHealth?
Applying for MassHealth CommonHealth requires three steps:
- General MassHealth Application (Form ACA-3)
- Disability Determination (Supplement A)
- Third Party Liability Form (for people with other primary insurance)
STEP 1: Begin by completing the general MassHealth Application (ACA-3)
There is one application (the ACA-3) for all MassHealth and Health Connector Plans. If your income is above a certain amount, you may receive a letter stating your child is denied because your income is too high. Don’t worry. All this means is that your child does not qualify for MassHealth Standard. You may also receive a letter that your child is eligible for a HealthConnector plan, which is not the same as MassHealth CommonHealth. Once you have completed the additional forms to document your child’s disability, described below, your application will be forwarded for a disability review to determine eligibility for MassHealth CommonHealth.
There are many ways to complete the ACA-3 Application for MassHealth
- Online – You can complete an online application (ACA-3) You will create an online account. It is important that you indicate you want help paying the premium and that your child has a potential disability. (If you have questions or need help, call MassHealth Customer Service as indicated below.)
- By Phone – You can call MassHealth Customer Service at (800) 841-2900 or TYY (800) 497-4648 and they can complete an application for you over the phone. (You will still need to submit the required verification documents.)
- By Mail – Go to the MassHealth Fill out a form “Massachusetts Application for Health and Dental Coverage and Help Paying Costs” (ACA-3). The application can be mailed to: Health Insurance Processing Center, P.O. Box 4405, Taunton, MA 02780. Note: It is NOT recommended that you submit the ACA-3 application by mail as it may take a very long time to process.
- By Fax – Fill out and sign the ACA-3 and fax it to (857) 323-8300.
- Other Assistance – You can also obtain help from a patient financial counselor at a local hospital, utilize a MassHealth Enrollment Center, or the services of Health Care For All (HCFA) to complete the process. HCFA is a free service that can assist you with completing an application and with follow-up and resolution of problems. HCFA can be reached at 1-800-272-4232. Many families find it is more convenient to rely on these experienced professionals to manage this process for them. There is no charge for this assistance.
CHECKLIST for STEP ONE
- ACA-3 Application – Complete the ACA-3 Application
- Be sure to indicate that you want help paying the premium, and answer “yes” to the question: “Does the person have a potential disability (PDI)?”
- Verification Documents: Required documents can be scanned and uploaded directly into your enrollment portal. You can also mail or fax these documents (in support of your application) to MassHealth at the address or fax number below:
- Proof of residency
- Proof of family income
- Proof of citizenship and identity
Mail or fax to:
Health Insurance Processing Center
PO Box 4405
Taunton, MA 02780
- View acceptable verification documents
- Provide a copy of two recent pay stubs. You do not have to send proof of social security or SSI income. If you are not working, submit an affidavit or “No-Income Form” available at the acceptable verification document link above.
- See “U.S. citizenship/national status and identity requirements for MassHealth/CommonHealth” found in the MassHealth Member Booklet. You only need to send proof of citizenship for the family member who is applying to MassHealth.
- Keep a copy of your entire application package for your
STEP 2: Additional information required to apply for MassHealth CommonHealth
- Fill out the MassHealth Disability Supplement, which is described below.
This information is submitted to UMass/Disability Evaluation Service. They will review your child’s disability request for Mass Health. The disability review process can take up to 90 days. To speed up this process, be sure to request the Disability Supplement at the same time as you get the MassHealth application (ACA-3).
- Pick the appropriate one of the two Disability Supplement forms, depending on your child’s age (under 18 or 18 or older). The form tells the review office about your child’s medical and mental health providers, daily activities, and educational background. Also, if you have any of the following, make a copy and include with the application:
- Your child’s medical records;
- Individualized Family Services Plan (IFSP);
- Individualized Educational Plan (IEP), testing; or
- Other records that describe your child’s condition(s)
- ALSO, complete the MassHealth Medical Records Release Form for EACH heath provider (or educator) who has information about your child’s disability.
This form can be found with the Disability Supplement application. It gives the Disability Evaluation Services Unit permission to contact your child’s health provider(s) for more information about your child’s medical condition(s). This information helps MassHealth decide if your child is disabled under state and federal law. Fill out a separate release form for each health provider. If your child is in Early Intervention or has an IEP or 504 plan at school, also fill out a release form for these providers/teachers. Be sure to sign each form.
Mail the completed application and copies of all of the above to:
Disability Evaluation Services / UMASS Medical DES
P.O. Box 2796
Worcester, MA 01613-2796
Or send by fax to: 774-455-8156; or email to: DESmailroomteam@umassmed.edu
If you need help filling out these forms, you can call the UMass/Disability Evaluation Services Help Line at 1-888-497-9890. After you have sent in this information, a staff member from the UMass/Disability Evaluation Service may contact you if more information is needed.
- Follow-up with your child’s medical or mental health providers
- Make sure your child’s medical or mental health providers have responded to the UMass/Disability Evaluation Service’s request(s) for information about your child.
COMBINED MASSHEALTH + COMMONHEALTH CHECKLIST (STEPS 1 and 2)
- ACA-3 Application – completed online or over the phone
- Documents to mail or fax to MassHealth to apply for MassHealth
- Proof of family income
- Proof of citizenship
- Proof of identity
- Documents to mail or fax to MassHealth in support of MassHealth CommonHealth disability status
- Filled out MassHealth Child Disability Supplement or Adult Disability Supplement
- Filled out MassHealth Medical Records Release Form(s) – be sure to sign all release forms included in the application
- Copies of records that describe your child’s condition, such as medical records, an Individualized Educational Plan (IEP), an Individualized Family Services Plan (IFSP), and psychological testing results.
- Keep a copy of your entire application package for your record
Step 3: Third Party Liability Form (TPL)
- After your child has been approved for CommonHealth, also complete the TPL (Third Party Liability) form, which confirms to MassHealth that you have the required primary or employer-sponsored health insuranc
- Return the form by mail or fax to the address/phone number listed at the bottom of the Third Party Liability form.
Once TPL is confirmed, benefits through the Mass Behavioral Health Partnership (MBHP) will be added to the CommonHealth plan. In this way, your child can access ABA.
Premium Assistance (PA)
The MassHealth Premium Assistance (PA) program is for MassHealth members who have access to employer-sponsored health insurance (ESI) through a parent, or job, or other source. Not all ESI plans are eligible, but if they are, PA can often be a substantial financial benefit. The AIRC can help explain some of the eligibility requirements.
Once CommonHealth is active, call the office of MassHealth Premium Assistance at 1.800.862.4840 to apply for Premium Assistance. If your ESI plan is eligible, Premium assistance may cover some, or all, of what you pay for your family’s health plan. PA will reimburse what you pay for your ESI, by subtracting PA from the assessed CommonHealth premium. The result is a:
- lower monthly CommonHealth premium or
- check mailed to you for the difference (if the assessed CommonHealth premium is less than the premium assistance amount.)