Follow up from June HCWG Meeting on PCA Prior Auth & "Referred Eligibles"
Hi Everyone,
At last week's meeting we heard about PA Prior Authorization and were cut short hearing about "referred eligibles." Attached & set out below is more information about both.
PCA Prior Authorization.
Attached are a few of the charts we showed you at last week's meeting about PCA Prior Authorization decision outcomes. I've omitted the charts specific to children until we can confirm the info with MassHealth. We also corrected a mix up in the bar chart.
Referred Eligibles: MassHealth & DTA
Some people obtain MassHealth based on an application for TAFDC or EAEDC cash benefits from DTA --this is a group MassHealth calls "referred eligibles."
MassHealth & DTA have made progress addressing concerns initially raised about Haitian families in EA Shelter who applied for cash benefits through DTA but did not have the correct MassHealth coverage but experienced by other "referred eligibles" too.
Also attached are slides presented by MH-DTA at our meeting with them in June with more details on new noticing and training improvements.
The bottom line is that if a family in EA shelter is receiving TAFDC or a single adult/couple in an adult shelter is receiving EAEDC they will have comprehensive MassHealth coverage, not MH Limited. If a health care provider cannot find them in the Eligibility Verification System (EVS), the family should be able to get their MH ID number from DTA or on their own using MyServices https://myservices.
If a healthcare provider looks in EVS & sees Haitian Entrants as having only MH Limited it most likely means one of two things,
1. There is a duplicate application that failed to correctly identify them as Haitian Entrants and was not linked with the DTA case due to some name-spelling or other ID discrepancy. The solution here is to check EVS for alternate spellings or get the MH ID No from DTA or My Services, and to call the MEC to fix the discrepancy in the duplicate MH case, or
2. The family only had a provisional MH fee for service coverage while their TAFDC application was pending, but never actually qualified for a cash benefit, and the 30 day provisional period has now expired or DTA has found them ineligible for TAFDC in less than 30 days. These families will have to apply directly to MassHealth to obtain coverage.
The same issues may arise for single adults and couples who apply for EAEDC. However, here is also an added problem for EAEDC applicants 65 and older. Once they apply for EAEDC, they automatically qualify for an EAEDC medical benefit defined at 130 CMR 450.106. The EAEDC medical benefit is not the same benefit as MassHealth Limited. Once they are approved for EAEDC by DTA, they should qualify for Standard, CarePlus or Family Assistance depending on their age and immigration status BUT it is not automatic. MEC workers must assign them to one of these benefits. If that does not happen, and they stay in the EAEDC benefit, the SSU should now be able to fix these cases.
If you continue to see these or related eligibility problems, please refer your clients to any of the groups that have been participating in these meetings with MassHealth & DTA and that also provide direct client services: GBLS (greater Boston), HCFA and HLA (both statewide). Also feel free to get in touch with Vicky Pulos at MLRI, but please don't refer clients or patients directly to her.