One Care Medicare + MassHealth Important Updates

1. One Care Medicare + MassHealth Important Updates

2. Key Updates for Counselors Eligibility Criteria One Care Plans and County Guide Enrollment Timeline and Types of Enrollment Continuity of Care (Enrollment Process) Grievances and Appeals SHINE Counselors Role MassHealth Contact Information Additional Resources

3. Who is eligible? Dual eligibles with Medicare and MassHealth (Standard or CommonHealth) between the ages of 21-64*. Approximately 90,240 Massachusetts residents are included in this target population. Individuals enrolled in a SCO, PACE, Frail Elder Waiver or other Home and Community Based Service Waivers are not eligible. Eligible beneficiaries can opt-in, switch One Care Plans, or opt-out at any time by contacting MassHealth Customer Service. The above actions are effective the first day of the following month a change is requested. * A One Care member turning 65 can stay in their One Care plan as long as they remain eligible for MassHealth.

4. One Care Plans Three companies are offering One Care Plans in select counties in Massachusetts: 1) Commonwealth Care Alliance Contact: 1-866-610-2273, www.commonwealthonecare.org 2) Fallon Total Care Contact: 1-800-879-0852, www.fallontotalcare.org 3) Network Health Contact: 1-855-393-3154, www.chooseunify.com

5. Which Counties Will Have Access to One Care? * One Care is available in Plymouth County except for the following towns: Wareham, E. Wareham, W. Wareham, Lakeville, Marion and Mattapoisett One Care is not available in Barnstable, Berkshire, Bristol, Dukes, and Nantucket County.

6. Types of Enrollment Enrollment into One Care will vary depending on the county in which a beneficiary resides. All eligible beneficiaries will receive an Enrollment Guide from MassHealth in September. Self Selection (Voluntary Enrollment):Eligible duals living in Essex, Franklin, Middlesex, Norfolk, and parts of Plymouth County* can voluntarily enroll into One Care. Auto-Assignment (Automatic Enrollment):Eligible duals living in Hampden, Hampshire, Suffolk and Worcester County will be automatically assigned to a One Care plan if they do not take action to opt-in or opt-out. *One Care is available in Plymouth County excluding the following towns: Wareham, E. Wareham, W. Wareham, Lakeville, Marion and Mattapoisett Note: Only counties with 2 or more One Care plans are subject to auto-enrollments . This only effects Hampden, Hampshire, Suffolk and Worcester County.

7. Time Line of Important Dates

8. Time Line Continued…

9. Time Line Continued…

10. Process for Voluntary and Automatic Enrollments Enrollment in One Care is effective the first day of the following month in which the enrollment is submitted. Within 90 days of enrollment, a Personal Care Plan is developed to ensure the member’s range of needs are identified, addressed, and supported by the plan. Before the Personal Care Plan is implemented, the member must approve it. During this 90 day period, the member can continue to see their current healthcare providers and One Care will be responsible for payment. Members will not be denied access to covered services during this time. Once the member approves the Personal Care Plan, the plan is implemented and the member must receive care from network providers only.

11. Personal Care Plan Each One Care member will have an individually designed Personal Care Plan outlining their various physical, mental health, and long-term care needs. The Personal Care Plan will be developed by the member along with the help of their assigned care team. The care team will consist of a care coordinator in a addition to providers, long-term support coordinator, family members or any combination of advocates the member would like involved. Before the Personal Care Plan is implemented the member must approve it. Before approval, the member will have awareness of plan providers and coverage information.

12. Process for Opting Out When an individual wants to opt-out of One Care: Action is required. The beneficiary should complete and return the Enrollment Decision Form or call MassHealth Customer Service to officially opt-out. The member will revert back to their Medicare and MassHealth benefits. Upon opting-out, the beneficiary will not be subject to future auto-assignments.

13. Grievances and Appeals Appeals: Members have the right to file an appeal to dispute changes made to coverage such as: denials, terminations, reduced services, or delayed access to coverage. Instructions on how to file an appeal will be available in the plan’s One Care Member Handbook. Grievances:Members have the right to file a grievance to report issues related to quality of care, customer service concerns or failures to uphold patient rights. Instructions on how to file a grievance will be available in the plan’s One Care Member Handbook. Ombudsperson: There will be an independent Ombudsperson role developed to impartially resolve disagreements, problems with service plans, and denials of service. The contact information for this resource will be made available in fall 2013. Depending on the situation, appeals may be handled by Medicare, MassHealth, or One Care. Contact the One Care Plan first for specific instructions.

14. Role of SHINE Counselor Assist eligible beneficiaries to understand what One Care is, review choices, check provider networks, check drug formularies and describe the enrollment process. Complete the client contact form, including new data fields, as required by CMS

15. MassHealth Contact Info To opt-in, opt-out, or switch plans, members will call MassHealth directly or submit their Enrollment Decision Forms by fax or mail. MassHealth Customer Service : 1-800-841-2900; TTY 1-800-497-4648 MassHealth Fax number : 617-988-8975 MassHealth Mailing Address: One Care PO Box 1200 Boston, MA 02112

16. Additional Resources Visit the One Care Website: www.mass.gov/masshealth/onecare One Care Introduction Webinar One Care Member Booklet One Care Consumer Brochure One Care FAQ Visit the SHINE Counselor Website: shinecounselor.800ageinfo.com One Care Fact Sheet for SHINE Counselors One Care Time Line of Important Dates One Care List of Covered Services