Joint Committee on Health Care Financing
The Massachusetts Health & Hospital Association (MHA), on behalf of our member hospitals, health systems, physician organizations and allied health care providers, appreciates the opportunity to submit comments in strong support of HB1153 / SB679, An Act relative to newborn enrollment in MassHealth.
The MassHealth program cares for approximately 1.76 million patients. For more than 1.1 million commonwealth residents, MassHealth serves as their primary health insurance coverage. In this latter group, the vast majority of individuals are required to be enrolled in some form of managed care program. Currently, these individuals are enrolled in 17 Accountable Care Organizations (ACOs), two Managed Care Organizations (MCOs), and the Primary Care Clinician (PCC) program. New and existing enrollees are permitted to choose a managed care offering that best meets their medical needs. If enrollees do not choose a plan, MassHealth assigns them to a plan based on an auto-assignment logic. In the case of newborns, MassHealth auto-assigns the newborn to the mother’s managed care plan, including ACOs, MCOs, or the PCC plan.
With the introduction of the new MassHealth ACO program, many more managed care offerings are now available -- thereby spreading enrollment across more health plans. Beyond the expansion of the number of managed care offerings, the ACO program also introduced a key policy change affecting member assignment to plans. Individuals in MassHealth managed care are required to have a primary care physician (PCP). Prior to the ACO program that went live in March 2018, PCPs could care for members in various MCOs and the PCC program. Under the new ACO program, PCPs participating in a MassHealth ACO are now exclusive to a single ACO. With this change, the likelihood that a newborn’s pediatrician is not in the mother’s managed care plan has increased significantly given the new PCP exclusivity for pediatricians participating in ACOs.
Healthcare providers have raised concerns about the current policy that auto-assigns newborns to a health plan based on their mother’s managed care enrollment, as the plan often does not include the baby’s pediatrician. These instances apply to all aspects of MassHealth managed care -- whether the mother is in an MCO, ACO, or the PCC program. Families and pediatric offices are currently facing challenging administrative enrollment issues during the initial health visits for many newborns. In many cases, healthcare providers have cared for these newborns without reimbursement due to MCO and MassHealth claims processing denials for network and referral requirements.
In an ideal world, MCO and ACO plan changes would become effective the same day -- no matter the day of the week. However, MassHealth has system and eligibility process limitations that likely prevent such a resolution. Despite the improvements made in MassHealth eligibility systems in recent years, working with MassHealth customer service to enroll in a new health plan requires time that extends beyond the same day of a newborn’s first visit to their pediatrician. MHA and healthcare providers continue to work with MassHealth on other workarounds but we believe a substantive resolution is needed to address the core problem stemming from the current newborn auto-assignment process.
HB1153 / SB679 provides such a solution as it requires that the first forty-five days of MassHealth eligibility for newborns be managed under the fee-for-service program. If a family does not choose a plan for their newborn by day forty-six, then the baby can be auto-enrolled into the mother’s health plan or a plan that includes other children in the household. Based on feedback from MHA member ACOs and healthcare providers, we believe the 45 day period will allow newborn parents and pediatric offices sufficient time to work with MassHealth to enroll a baby into the appropriate managed care plan without the unwanted stress of dealing with the complexities of out-of-network and referral requirements for these initial primary care visits. We believe this window will allow time for families to research the managed care plan – whether an ACO, MCO, or PCC plan – that best meets their newborn’s needs and work through the MassHealth customer service process.
HB1153 / SB679 does not prohibit enrollees from being enrolled into a managed care plan earlier than 45 days if the family proactively chooses a plan for their newborn. If a family were to select a plan prior to day 45, we believe the newborn should be enrolled into that health plan prior to day 45. If no managed care plan is selected by day 45 but is required, auto-assignment should continue as it does today.
We believe this short and limited carve-out will have no material effect on efforts to coordinate care or on the MassHealth budget. While MCOs play a role in the long-term management of care -- especially for those with chronic and complex conditions -- newborn care during the first weeks of life is, for the most part, managed by pediatricians and pediatric specialists, if needed. Regarding the financing of this care, MassHealth fee-for-service rates are also the lowest paid for these services; therefore, using the fee-for-service rates will not increase MassHealth expenditures. Many families will not require the full 45 days to choose a managed care plan. While there may be workarounds to this problem currently under consideration, we ultimately believe a more holistic solution is needed as provided by HB1153 / SB679.
MHA respectfully requests the committee report HB1153 / SB679 favorably in order to improve the experience of MassHealth parents with newborns, and reduce unnecessary administrative challenges for families and healthcare providers during the first weeks of newborn care. We thank you for your consideration of this issue. If you have any questions or concerns or require further information, please contact Michael Sroczynski, MHA's Senior Vice President of Government Advocacy at (781) 262-6055 or msroczynski@mhalink.org