130 CMR, § 508.007

Current through Register 1533, October 25, 2024

Section 508.007 - Integrated Care Organizations

(A)Eligibility.

(1) In order to be eligible to enroll in an integrated care organization (ICO), a MassHealth member must meet all of the following criteria, and may not be enrolled or concurrently participate in any of the programs or plans listed in 130 CMR 508.007(F):

(a) be 21 through 64 years of age at the time of enrollment;

(b) be eligible for MassHealth Standard as defined in 130 CMR 450.105(A): MassHealth Standard or MassHealth CommonHealth as defined in 130 CMR 450.105(E): MassHealth CommonHealth;

(c) 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: Definition of Terms; and

(d) live in a designated service area of an ICO.

(2) If a member is enrolled in an ICO and turns 65 years old and is eligible for MassHealth Standard or MassHealth CommonHealth, he or she may elect to remain in the ICO beyond 65 years of age.

(B)Selection Procedure and Assignment to an ICO.

(1) The MassHealth agency will notify members

(a) of the availability of an ICO in their service area and how to enroll in an ICO;

(b) that, in any service area with at least one ICO, MassHealth may assign eligible members who do not choose an ICO but have not opted out of the Duals Demonstration; and

(c) how to opt out of the Duals Demonstration.

(2) An eligible member may enroll in any ICO in the member's service area by making a written or verbal request to MassHealth or its designee. A service area is the specific geographical area of Massachusetts in which an ICO agrees to provide ICO services. Service listings can be obtained from the MassHealth agency or its designee. The list of integrated care organizations (ICOs) that the MassHealth agency will make available to members will include those ICOs that contract with the MassHealth agency and provide services within the member's service area. ICOs are also referred to as One Care plans. Members enrolled in an ICO (One Care plan) are participants in the Duals Demonstration, also known as One Care.

(3) MassHealth provides written notice at least 60 days in advance of its assignment of any eligible members to an ICO. The notice includes the ICO to which the member is being assigned, information about how to enroll in a different ICO, if available, and information about how to opt out of the Duals Demonstration.

(C)Obtaining Services When Enrolled in an ICO. When a member is enrolled in an ICO in accordance with the requirements under 130 CMR 508.007(A), the ICO will authorize, arrange, integrate, and coordinate the provision of all covered services for the member. Upon enrollment, the ICO 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 an Integrated Care Organization. A member may disenroll from an ICO at any time by notifying the MassHealth agency or its designee verbally or in writing. A member who disenrolls from an ICO, but does not select another ICO or opt out of the Duals Demonstration, may be automatically assigned another ICO provided that MassHealth provides a written notice at least 60 days in advance of any auto assignment. The notice includes the ICO to which the member is assigned, information about how to enroll in a different ICO if available, and information about how to opt out of the Duals Demonstration. Disenrollment requests that are received by the MassHealth agency on the last calendar day of the month will be effective on the first day of the following month.

(E)Disenrollment from the Duals Demonstration. A member may opt out of the Duals Demonstration at any time by notifying the MassHealth agency or its designee verbally or in writing. Requests that are received by the MassHealth agency on the last calendar day of the month will be effective on the first day of the following month.

(F)Other Programs. A member may not be enrolled in an ICO 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 an ICO;

(3) any Medicare Demonstrations wherein concurrent participation in the Duals Demonstration 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 an ICO must make copayments in accordance with the ICO's MassHealth copayment policy. Those ICO copayment policies must

(1) be approved by MassHealth;

(2) exclude the persons and services listed in 130 CMR 506.014: Copayments Required by MassHealth and 520.037: Copayment and Cost Sharing Requirement Exclusions;

(3) not exceed the MassHealth copayment amounts set forth in 130 CMR 506.015: Copayment and Cost Sharing Requirement Exclusions and 520.038: Services Subject to Copayments; and

(4) include the copayment maximums set forth in 130 CMR 506.018: Maximum Cost Sharing and 520.040: Maximum Cost Sharing. (See also 130 CMR 450.130: Copayments Required by the MassHealth Agency.)