Section 12: Membership Overview

MEMBER SERVICES DEPARTMENT

Members may call our Member Services department at:

1-888-566-0010 (MassHealth)

1-877-957-5300 (Commonwealth Care)

1-877-492-6967 (Commercial plans)

1-866-765-0055 TTY/TDD Line (for all deaf or hearing-impaired members)

Member Services representatives are available:
8:00 a.m. to 6:00 p.m., Monday through Friday (except holidays)

Holidays when BMC HealthNet Plan is closed:
New Year’s Day Martin Luther King, Jr. Day Presidents Day Patriots Day Memorial Day	Independence Day Labor Day Thanksgiving Day Christmas Day

Behavioral Health: MassHealth members may contact the Behavioral Health hotline at 1-888-217-3501; Commonwealth Care and Commercial plans members may call 1-877-957-5600. Staff is available to answer member questions related to behavioral health services 24 hours a day, seven days a week.

12.1 Member Enrollment in BMC HealthNet Plan

MassHealth or Commonwealth Care membership: To become a member of BMC HealthNet Plan, a Massachusetts resident must qualify for one of these coverage options through MassHealth or the Connector. The individual or families seeking membership must apply by filling out a Medical Benefits Request (MBR) form. Many community-based organizations, hospitals, and community health centers will assist those seeking membership with the MBR or help them to apply through an electronic application called the Virtual Gateway. Applicants can also fill out the MBR on their own by downloading, completing and mailing the application using the instructions on the sheet. The law requires that an applicant provide the Commonwealth of Massachusetts with income information, an employment record, any disability or illness information, a list of family members, proof of citizenship, identity (i.e., government-issued identity card), or immigration status and other details. The Commonwealth will then notify the applicant if he or she is eligible for either MassHealth or Commonwealth Care.

If MassHealth or the Connector determines that an applicant is eligible, s/he becomes a Plan member in one of the following ways:

The member chooses BMC HealthNet Plan.
MassHealth or the Connector (for Commonwealth Care program) enrolls the member in BMC HealthNet Plan.
The member is transferred to BMC HealthNet Plan from another managed care organization (MCO).

Commonwealth Care only: Members must be adults aged 19 and older. Children are not eligible for coverage under this plan. Coverage is determined on an individual basis. Members will be eligible as of the first of the month after their confirmed managed care organization selection or assignment. If a member is deemed eligible during the last two days of a month, that member will not be eligible until the first day of the following month. Once an individual is enrolled in the Plan, s/he is typically a member for the remainder of the contract year (July 1 through June 30).

Commercial plans membership: Eligible Massachusetts residents may enroll in one of our Commercial plans through one of these means:

Through the Connector: The Connector offers BMC HealthNet Plan ‘Commonwealth Choice’ plans to eligible individuals (non-group) and their families, and to the employees (and their dependents) of small employer groups (1-50 employees). Eligibility determinations for Commonwealth Choice are made by the Connector.
Directly through BMC HealthNet Plan: Eligible small groups (1-50 employees) may enroll in one of our Commercial plans – known as ‘Employer Choice’ - by calling us directly. We will make eligibility determinations according to our eligibility standards.

12.2 MassHealth Membership Overview

12.2.1 MassHealth Benefit Categories and Eligibility Criteria for BMC HealthNet Plan Membership

We offer the following four MassHealth benefit categories (further described below):

MassHealth Basic
MassHealth Family Assistance
MassHealth Standard
MassHealth Essential

MassHealth, not BMC HealthNet Plan, determines eligibility for all individuals applying for MassHealth benefits. If an applicant meets eligibility criteria and the application is approved, MassHealth assigns the member to one of the benefit categories listed above based on the applicant’s income level, age, and family status.

Note that the Plan contracts with an outside vendor to help eligible disabled members upgrade their benefit category from Standard or Basic to Supplemental Security Income (SSI), if appropriate. This contractor also assists eligible members with applying for SSI benefits that may lead to a change in his/her MassHealth category of assistance. The contractor may also contact you to access medical records, or to visit the member during a hospital stay or scheduled appointment at your site. We expect you to assist this contractor in any way possible. Below is a description of the eligibility criteria for each MassHealth recipient category.

12.2.1.1 MassHealth Basic Plan

Members may be eligible for the MassHealth Basic plan if their family's income before taxes and deductions is no more than 100% of the federal poverty level and if they meet one or more of the following standards:

are under the age of 65 and are getting services or are on a waiting list to get services from the Department of Mental Health
are currently not working
have not worked in more than one year or, if have worked, have not earned enough to collect unemployment
are not working and are not eligible to collect unemployment benefits

12.2.1.2 MassHealth Family Assistance Plan

Members are eligible for MassHealth Family Assistance if their family's income before taxes and deductions is no more than 200% of the federal poverty level and if they meet one of the following standards:

are aged 1-18
are under age 65 and working, and are not eligible for MassHealth Standard or MassHealth CommonHealth
work for a qualified employer who participates in the Insurance Partnership
have employer-sponsored health insurance that meets MassHealth standards, and pay part of the cost of that health insurance, or are under age 65 and HIV positive and not eligible for MassHealth Standard or MassHealth CommonHealth

Certain uninsured children may be eligible with income up to 300% of the federal poverty level.

12.2.1.3 MassHealth Standard Plan

This benefit category includes both Standard Disabled and Standard Aid to Families with Dependent Children (AFDC) populations. Members are eligible for the MassHealth Standard plan if they meet the income standard and belong to one of the groups listed below:

for pregnant women: at or below 200% of the federal poverty level
for children under age one: at or below 200% of the federal poverty level
for children aged one through 18: at or below 150% of the federal poverty level
for parents or caretaker relatives of children under age 19: at or below 133% of the federal poverty level
for disabled adults: at or below 133% of the federal poverty level

12.2.1.4 MassHealth Essential Plan

MassHealth Essential includes MassHealth-eligible individuals over age 18 and under age 65, who qualify under MassHealth Essential eligibility criteria which includes persons:

not currently working
that have not worked in more than one year or, if a person has worked, that person has not earned enough to collect unemployment
not eligible to collect unemployment benefits
who have an immigration status that prevents them from getting MassHealth Standard, are long term unemployed and meet MassHealth disability rules; and
that are not eligible for MassHealth Basic
that are U.S. citizens or eligible non-citizens (non-citizens with special status quality for Essential only if they are disabled. If there is a spouse, the spouse must be working no more than 100 hours per month.)

Additionally, college students who can get health insurance from their college or university and persons whose spouses work more than 100 hours a month also are not eligible for MassHealth Essential.

12.3 Commonwealth Care Membership Overview

12.3.1 Commonwealth Care Eligibility Criteria

We offer the following three Commonwealth Care benefit plan types:

Plan Type I
Plan Type II
Plan Type III

The Connector, not BMC HealthNet Plan, is responsible for all eligibility determinations. Individuals who do not pay a premium either self-select a managed care organization (MCO), or if they do not choose an MCO, the Connector will automatically assign them to one in their area. Individuals who pay a premium have the option to self-select an MCO. Once a member selects or is assigned to an MCO, he/she has 60 days to change MCOs. If a change is not made, he/she is locked-in for the remainder of the contract year (July 1 through June 30) and may only switch MCOs by obtaining a waiver from the Connector.

12.3.2 Commonwealth Care Eligibility Categories

Members are eligible for Commonwealth Care if they meet all of the following criteria and the income standard:

Uninsured and ineligible for health insurance through Medicaid/Medicare, their employer, or their spouse’s employer for at least the last six months
Income before taxes is at or below 300% of the federal poverty level
U.S. citizen or a U.S. qualified alien or alien with special status
Massachusetts residency
Age 19 or older. (Eligible persons under age 19 may be covered by MassHealth. BMC HealthNet Plan participates in both programs.)

Plan Type	Income
I	< =100% Federal Poverty Level (FPL)
II	100.1% - 200% FPL
III	200.1% - 300% FPL

12.4 Commercial Membership Overview

The six Commercial plans offered by BMC HealthNet Plan are:

BMC HealthNet Plan Bronze Saver
BMC HealthNet Plan Bronze Value
BMC HealthNet Plan Bronze Plus
BMC HealthNet Plan Silver Saver
BMC HealthNet Plan Silver Plus
BMC HealthNet Plan Gold

Who is eligible for this product?

Individuals – Person purchases insurance on his or her own without an employer contributing to the premium. The individual can cover all eligible members of his/her family. Individual, Individual plus one, Individual plus family are all qualifiedly coverage types for this product. This category of eligibility is called nongroup.
Small businesses with 1 to 50 employees. This is a small business of from one (self-employed) through 50 employees. Eligible employees and their eligible family members can be insured through small group.

Note: Individuals and employer groups’ employees must reside in BMC HealthNet Plan’s service area to be enrolled in the Commercial plans.

12.5 Overview of BMC HealthNet Plan Benefits

We offer comprehensive benefit packages for MassHealth, Commonwealth Care and Commercial plans offerings. Please see section 13 for information on the benefits available to Plan members.

12.5.1 Member Self-Referral Services

We don’t require referral forms. However, in the interest of good communication between you and our members, we instruct each member to contact his or her PCP before seeking non-emergent healthcare services. There are some services for which a member may self-refer for care rather than having a PCP direct his/her care. Plan pre-authorization requirements and compliance with clinical criteria still apply to certain member self-referral outpatient specialty services and inpatient admissions.

See section 3 for a list of medical/surgical services for which members may self-refer for care if delivered by a Plan participating provider within the member’s PCP-affiliated network.

A member may also self-refer for certain outpatient behavioral health services rather than being directed by their PCP if the service is provided by a contracted Beacon Health Strategies-Plan provider. The Plan contracts with Beacon Health Strategies to manage the Plan’s behavioral health program. Please direct all behavioral health inquiries to Beacon Health Strategies at beaconhealthstrategies.com or call Beacon at 1-866-444-5155.

Some supplies and services do not require referrals. Please see section 13 for information on the benefits available to Plan members, or go to bmchp.org for details.

12.5.2 Special Programs and Items for Members

In addition to the clinical programs available for our members, we offer members several special programs and items that supplement their benefits.

For MassHealth, these extra programs and items include:

Free infant and toddler car seats and child booster seats
Free bicycle helmets for children
Free manual breast pumps for nursing mothers
Member Services department and Behavioral Health toll-free hotline to answer members’ questions
Member newsletter
Coordination of the MassHealth transportation benefit for qualified members
Care management for special populations
Free access to our Nurse Advice line
Free access to our Audio Health Library
Free Dental Kits, including electric toothbrush (members 4 and older)
Reimbursements for Weight Watchers® and fitness club memberships

For Commonwealth Care, these extra programs and items include:

Free manual breast pumps for nursing mothers
Reimbursements for Weight Watchers® and fitness club memberships
Member Services department and Behavioral Health hotline to answer members’ questions
Member newsletter
Care management for special populations
Free access to our Nurse Advice Line
Free access to our Audio Health Library
Plan Type II and Plan Type III members are eligible for a 25% discount on dental services
Free dental kits, including electric toothbrush
Healthy Rewards Care – $55 card for getting annual checkup

For our Commercial plans, these extra programs and items include:

Reimbursements for Weight Watchers® and fitness club memberships
Member Services department and Behavioral Health hotline to answer members’ questions
Member newsletter
Care management for special populations
Free access to our Nurse Advice Line
Free access to our Audio Health Library

12.6 Member Identification Cards

Each MassHealth Plan member has two identification (ID) cards: a MassHealth-distributed member ID card and a Plan-distributed member ID card.

Each Commonwealth Care or Commercial plans member has one ID card, which is their Plan-distributed member ID card.

We mail a member ID card or enrollment letter to each member within five business days of enrollment. Below are the data elements included on the Plan’s member ID cards:

Plan name and logo
Member name
Plan member ID number: MassHealth and Commonwealth Care members are issued ID cards with a randomly generated eight-digit number prefixed with the letter B (e.g., B12345678). Commercial plans members are issued ID cards with a randomly generated eight-digit number prefixed with the letter C (e.g., C12345678). This number is followed by a two-digit suffix indicating whether the card is issued to the subscriber or a dependent.
BMC HealthNet Plan’s identification cards are not recognized by the state's Eligibility Verification System (EVS). You can verify a member's eligibility status for both MassHealth and Commonwealth Care by entering the member's name and birth date in EVS, which will quickly verify eligibility status. When submitting claims to the Plan, you must use the member's ID number from the Plan-issued ID card.
MassHealth member ID number (MassHealth members’ cards only). When submitting claims to the Plan, use the member's Plan ID number from the Plan-issued ID card.
Pharmacy benefits manager
Telephone numbers for the Plan’s Member Services department, provider line, and the Behavioral Health hotline
Instructions on how to access services in the Plan

We instruct our MassHealth members to always carry their Plan member ID card and MassHealth ID card; they should present both cards to the treating provider at the time of service. Commonwealth Care or Commercial plans members receive only the Plan-issued ID card and need only present that card to receive services.

We encourage members to contact their PCP before receiving care, unless it is an emergency. You should not deny care if the member does not have his/her ID cards. Call our provider line at 888-566-0008 and select the member eligibility option to verify member benefits, eligibility, and PCP assignment in the Plan. You may also check member eligibility online at our website, bmchp.org. See section 8.2.6 for instructions on verifying member eligibility in the Plan.

If the information on the Plan’s member ID card is wrong, or a member did not receive his/her card, the member should call our Member Services department. If a member loses his/her Plan member ID card, s/he may request a new card at our website, bmchp.org, or call the Member Services department. Plan MassHealth members should contact MassHealth directly to receive a MassHealth replacement card.

12.7 Member Eligibility

Always check member eligibility – before delivering services – on the date of service and daily during inpatient admissions. See section 8.2 for instructions on how to check member eligibility.

12.8 PCP Selection and Assignment

We proactively assist and encourage each member to select his/her own PCP and other healthcare professionals to the extent possible; we give each member information to assist him/her in selecting a provider (e.g., physician specialty, geographic location, and experience with special populations). (Note that our Member Services department provides interpreter services for members when they call, if necessary, and/or if requested by the member.) If we do not obtain a PCP selection from the member (or the member’s designee), we assign an appropriate PCP no later than 15 calendar days after the member’s enrollment date in the Plan.

If a PCP assignment is required, the member is assigned to a participating PCP using the following criteria:

If a member was previously enrolled in the Plan, the PCP assignment will be the member’s most recent PCP (if the assignment remains appropriate).
If the member has not been enrolled in the Plan before, we consider the following criteria when assigning a PCP to the member:
- Member’s health needs
- PCP’s training and expertise with demographic or special populations similar to the member’s
- Geographic proximity of the PCP’s site to the member’s current residence
- PCP site’s accessibility to public transportation
- PCP site’s ability to accommodate the member’s disability, if applicable
- Capabilities of the PCP to practice in the member’s preferred language
- PCP’s access to medical interpreters for the member’s preferred language
The member’s age should be appropriate for the PCP’s specialty and training:
- Pediatrics - birth to age 21
- Internal Medicine - age 18 or older
- Family Medicine - all age categories
An obstetrician/gynecologist (OB/GYN) can serve as a PCP if selected by a female member, but the Plan will not assign a member to an OB/GYN practice for primary care services without a member request.

If the member does not select his/her own PCP, we will inform the member of the PCP assignment that we made. We can assist the member in scheduling an initial appointment with the PCP.

12.8.1 Request for PCP Change

Our MassHealth members may request a change in their PCP at any time; Commonwealth Care and Commercial plans members may request a change only three times a year.

A member may request a change in his/her PCP assignment for any reason in any of the following ways:

Complete, sign, and fax a Primary Care Provider Selection Form to our Enrollment department. Enrollment in the new PCP’s member panel is effective the date the member signs the form. See section 15 for a sample form (which includes the fax number for our Enrollment department).
Call the Member Services department at 888-566-0010 (MassHealth), 877-957-5300 (Commonwealth Care) or 877-492-6967 (Commercial plans between 8 a.m. and 6 p.m., Monday through Friday (except holidays). Enrollment in the new PCP’s panel will be effective the next business day. We will transfer the member to the new PCP’s panel the same day if the member clearly states that s/he is in the PCP’s office and wants the transfer to be effective immediately.
Log in to the appropriate member portal at bmchp.org and submit the request online.

If this is the member’s first PCP selection, the PCP assignment will be effective on the member’s enrollment date into the Plan. Participating providers may assist members with a PCP selection or PCP transfer.

We monitor members’ voluntary changes in PCP selections to identify members with frequent changes. We will re-educate members on the role of the PCP or direct members for additional services, if necessary. Also, we will identify opportunities for provider education and quality improvement if transfers are related to provider performance or administrative issues.

12.9 Continuity of Care for New and Existing Plan Members

When medically necessary, we will arrange for a member to continue receiving treatment from his/her current, non-network provider. For MassHealth, this may occur for up to 60 calendar days from the member’s enrollment date if the member:

has a life-threatening, degenerative, or disabling disease or condition; or
is in the second or third trimester of pregnancy when she enrolls in the Plan.

For new Commonwealth Care or Commercial plans members, we cover services delivered by non-network physicians and nurse practitioners as follows:

For up to 30 days from the member's effective date of coverage if:
- the provider does not participate with another Commonwealth Care plan offered by the Connector, or does not participate in another commercial plan offered by the member’s group; and the provider is delivering an ongoing course of treatment or is the member’s PCP.
- the member is within her second or third trimester of pregnancy, in which case we will cover through the member's first postpartum visit.
- the member has a terminal illness, in which case we will cover until the member's death.

For existing Commonwealth Care or Commercial plans members, we may provide coverage for services provided by recently terminated (former) network providers in the following circumstances (in these cases the provider must not have been disenrolled from the Plan due to fraud or quality of care issues):

We may allow affected members continued access to their terminated PCP for at least 30 days after the effective date of the PCP’s termination from the Plan.
If the member is undergoing active treatment for a chronic or acute medical condition, we will cover continued treatment with the PCP or treating specialist through the current period of active treatment, or for up to 90 calendar days (whichever is shorter).
We will allow members who are in their second or third trimester of pregnancy continued access, through the postpartum period, to a terminated Plan provider who they had been seeing in connection with their pregnancy.
We will allow members who are terminally ill continued access to an involuntarily terminated practitioner until the member’s death.

For existing MassHealth members, we may provide coverage for services delivered by recently terminated providers in the following circumstances (in these cases the provider must not have been disenrolled from the Plan due to fraud or quality of care issues):

We may allow affected members continued access to their terminated practitioner for up to 90 calendar days after the effective date of the practitioner’s termination from the Plan if the member is undergoing active treatment for a chronic or acute medical condition. We will cover continued treatment through the current period of active treatment, or for up to 90 calendar days (whichever is shorter).
We may allow members who are in their second or third trimester of pregnancy continued access to a terminated Plan practitioner whom they had been seeing in connection with their pregnancy through the postpartum period.

12.10 Confidentiality and Provider Access to Member Information

Our staff complies with all applicable state and federal laws and regulations pertaining to confidentiality of member medical and personal records and confidentiality of the business and proprietary information of network providers. To ensure compliance, our staff will verify the identity of the provider or his/her designee seeking information that is considered protected health information (PHI) of a member under HIPAA, or personal information that is otherwise protected by law. The provider or his/her designee must give BMC HealthNet Plan the provider’s unique identifier, such as its federally issued tax identification number (TIN), National Provider Identifier (NPI), the BMC HealthNet Plan-assigned provider number (Legacy number), or other reasonable unique identifier before the Plan will release any PHI.

12.11 Member Rights and Responsibilities

Plan members have rights concerning health care and also certain responsibilities to their treating providers. We share this information with members and providers annually, or sooner, if policy changes occur. Please review the member’s rights and responsibilities as they are useful when explaining to members their responsibilities for adhering to certain Plan policies.

Please note that providers are responsible for ensuring member rights, as applicable.

12.11.1 Member Rights

In general, all members have the right to:

Receive information about the Plan, its services, our network providers, and member rights and responsibilities
Be treated with respect and recognition of their dignity and right to privacy
Participate with you in making decisions about their health care
Candid discussions of appropriate or medically necessary treatment options for their conditions, regardless of cost or benefit coverage
Voice complaints or appeals about the Plan or the care arranged for by the Plan
Make recommendations regarding our member rights and responsibilities policies

In addition, MassHealth members have the right to:

Receive the information required per the Plan’s contract with the state
Receive information about any illnesses he or she has, presented in a manner appropriate to the member’s condition and ability to understand
Have an open and honest discussion with you about appropriate or medically necessary treatment options for the member’s medical conditions, regardless of cost or benefit coverage. The member may be responsible for payment of services not included in the Covered Services list for his/her coverage type.
Receive information on available treatment options and alternatives, presented in a manner appropriate to the member’s condition and ability to understand
Participate in decisions regarding his or her health care, including the right to refuse treatment as far as the law allows, and to know what the outcomes may be
Be free from any form of restraint or seclusion, used as a means of coercion, discipline, convenience or retaliation
Freely exercise his or her rights without adversely affecting the way the Plan and its providers treat him/her
Request and receive a copy of his or her medical records and request that they be amended or corrected, as specified in 45 CFR 164.524 and 164.526
Be furnished with Plan covered services
Request an interpreter when s/he receives medical care
Request an interpreter when s/he calls or visits Plan offices (the Member Services department can provide an interpreter).
Have any printed materials from the Plan translated into his/her primary language, and/or to have these materials read aloud to him/her if member has trouble seeing or reading. Oral interpretation services will be made available upon request and free of charge.
Choose his/her PCP and change the PCP assignment at any time by calling our Member Services department or by faxing a completed Primary Care Provider Selection Form to the our Enrollment Department. See section 15 for a sample form (which includes the Enrollment department’s fax number).
Receive medical care within the timeframes described in section 8.3, Access to Care Guidelines for Medical/Surgical Services and to file an Internal Appeal if he/she does not receive care within those timeframes
Receive behavioral health care according to Beacon Health Strategies standards described in Beacon’s Provider Manual. The Plan contracts with Beacon Health Strategies to manage the Plan’s behavioral health program. Please direct all behavioral health inquiries to Beacon Health Strategies at beaconhealthstrategies.com or call Beacon at 1-866-444-5155.
Ask for a second opinion about any medical care his/her PCP advises the member to have
Receive emergency care 24 hours a day, seven days a week
Change his/her health plan at any time
Receive medical treatment from Plan providers without regard to race, age, gender, sexual preference, national origin, religion, health status, economic status, or physical disabilities. No provider should engage in any practice, with respect to any Plan member, that constitutes unlawful discrimination under any state or federal law or regulation
Receive information about the Plan, services, practitioners and providers and member rights and responsibilities
Expect healthcare providers to keep member records private, as well as anything members discuss with them. No information will be released to anyone without the member’s consent, unless permitted or required by law.
Voice a complaint and file a grievance with the Plan Member Services department and/or MassHealth customer service center about services received from the Plan or from a medical provider. The member also has the right to appeal certain decisions made by the Plan. Member grievances and internal appeals are described in Section 10.
Make recommendations about our Rights and Responsibilities statement.

12.11.2 Member Responsibilities

Responsibilities of all Plan members include the following:

Supplying information (to the extent possible) that the Plan and its network providers need in order to arrange for and provide care
Following plans and instructions for care that they have agreed on with their network providers
Understanding their health problems and participating in developing mutually agreed-upon treatment goals, to the degree possible
Discussing with his/her PCP when a specialist's services may be required or before s/he goes to the hospital (except in cases of emergencies or when s/he may self-refer for certain covered services. If a member self-refers to certain specialists, prior authorization may be required unless the specialist and the member’s primary care provider (PCP) are affiliated with the same hospital, or if the member is going to Boston Medical Center for specialty care.
Keeping appointments, being on time, and calling in advance if s/he is going to be late or have to cancel
A member must notify our Member Services department when he/she believes that someone has purposely misused Plan or MassHealth benefits or services.
Notifying our Member Services department and the MassHealth customer service center when member changes address or phone number
Paying for services not included in the Covered Services list for his/her coverage type

In addition, MassHealth members’ responsibilities include:

A member must tell his/her PCP the member’s health complaints clearly and provide as much information as possible.
A member must tell his/her PCP and/or treating provider about himself and his/her medical history.
A member must treat his/her PCP with dignity and respect.
A member must learn about any recommended treatment and consider it before receiving it.
A member must remember that refusing treatment recommended by his/her PCP might harm the member’s health.
A member must authorize his/her PCP to get copies of all the member’s medical records.
A member must receive all his/her health care from Plan providers, except in cases of emergency or self-referral. For services not covered by the Plan, but covered directly by MassHealth, which a member receives using his/her MassHealth member ID card, the member may receive the care from any MassHealth provider.
A member must not allow anyone else to use his/her Plan or MassHealth ID cards to obtain healthcare services.

In addition to the responsibilities above, Commonwealth Care members’ responsibilities include:

A member is responsible for paying all copayments/co-insurance for services. The Connector may waive copayments under non-premium-paying Plan Types due to financial or medical hardship. Members must contact the Connector to request a waiver.

12.12 Member Outreach and Communication

12.12.1 Member Marketing

We provide written marketing materials to potential members who express interest in Plan membership. If contacted by potential members, Plan representatives inform potential members of our eligibility guidelines, enrollment process, role of the PCP and the PCP selection process, and covered benefits. Plan staff complies with all marketing guidelines established by MassHealth and the Connector.

Additionally, MassHealth and the Connector require that Plan network providers abide by the guidelines below regarding marketing to individuals eligible for MassHealth and/or Commonwealth Care.

MassHealth and Commonwealth Care requirements for marketing to prospective Plan members

Do not make unsolicited personal contact with MassHealth Commonwealth Care patients (non-Plan members) about the Plan or any MCO to influence them to enroll in the Plan.
You may answer questions about our MassHealth and Commonwealth Care products if patients ask about them. You may also, or instead, refer them to the Plan (1-800-792-4355).
You may post approved Plan MassHealth and Commonwealth Care product brochures and posters in your facility.
If a MassHealth or Commonwealth Care patient wants to join the Plan, refer the patient to the appropriate state customer service line (MassHealth: 1-800-841-2900 or Commonwealth Care: 1-877-623-6765). The patient may use your phone, but do not make the call for him/her.
You may help any patients with their MassHealth or Commonwealth Care eligibility and applications.
In the course of treating a patient, you may talk to him or her about benefits or services available from an MCO, including the Plan, if the benefit or service relates to the patient’s treatment needs.
You may talk with Plan MassHealth or Commonwealth Care members about anything to do with their Plan membership, including extra items and services, choosing a primary care provider, how to get a new ID card, or other member questions. Please refer to the telephone numbers on the bottom of this page.

Provider responsibilities with respect to marketing to prospective plan members
As a Plan provider, you must comply with the following marketing requirements:

Marketing materials and communications cannot be inaccurate, false, misleading, confusing, discriminatory or fraudulent.
All marketing materials regarding the Plan must clearly state that information regarding all MassHealth/Commonwealth Care enrollment options is available from the MassHealth and/or Commonwealth Care toll-free customer service call center and website.
All written marketing materials must display the phone number and hours of operation of the MassHealth and/or Commonwealth Care customer service call center.

Approvals

Marketing materials developed by the Plan or its providers regarding the MassHealth Program require MassHealth approval.
Marketing materials developed by the Plan or its providers regarding the Commonwealth Care or Commonwealth Choice Commercial plans require Connector approval.
BMC HealthNet Plan will obtain MassHealth and/or the Connector’s approval. Please contact your Provider Relations representative if you have any questions or require assistance.

Marketing materials
Under the contract between BMC HealthNet Plan and MassHealth and/or the Connector, “Marketing Materials” are defined as:

Materials that are produced in any medium by or on behalf of the Plan, and that MassHealth or the Connector can reasonably interpret as marketing to eligible individuals. This includes producing and disseminating by or on behalf of the Plan any promotional materials or activities by any medium including, but not limited to, oral presentations and statements, community events, print media, audio visual tapes, radio, television, billboards, online, Yellow Pages, and advertisements that explicitly or implicitly refer to MassHealth and/or Commonwealth Care, and are targeted in any way toward eligible individuals.

Marketing
The MassHealth and Connector contracts define “Marketing” as:

Any communication from the Plan, its employees, providers, agents or material subcontractors to an eligible individual who is not enrolled in the BMC HealthNet Plan that MassHealth or the Connector can reasonably interpret as influencing the eligible individual to enroll in BMC HealthNet Plan, or either to not enroll in, or to disenroll from, another contracted MCO’s Plan. This includes producing and disseminating by or on behalf of BMC HealthNet Plan any marketing materials. Marketing does not include any personal contact between a provider and an eligible individual who is a prospective, current or former patient of that provider regarding the provisions, terms or requirements of MassHealth or Commonwealth Care as they relate to the treatment needs of that particular eligible individual.

Examples of marketing
- Letters or materials urging a patient to enroll in the Plan or any particular MassHealth or Commonwealth Care health plan
- Communications with patients urging them to disenroll from any particular MassHealth or Commonwealth Care plan
Examples of what IS NOT marketing
- Information to patients or members regarding how to access care, new services, personnel, enrollee education materials, care management programs, and provider site information
- Personal communication between a provider and a patient regarding the provisions, terms or requirements of MassHealth as they relate to the treatment needs of that particular member.

MassHealth and Connector approval
If a communication is determined to be Marketing material, it must comply with the content requirements described above, and will need to be approved by MassHealth and/or the Connector 30 days prior to distribution. BMC HealthNet Plan is responsible for obtaining these approvals.

12.12.2 Member Services Department

Our Member Services department is available to members Monday through Friday, 8 a.m. to 6 p.m. (except holidays). Members may call the Member Services department toll free at 1-888-566-0010. If necessary, a Member Services representative will arrange for another staff member to speak with a Plan member in his/her primary language, use an interpreter free of charge, coordinate TTY/TDD services for members who are deaf or hearing-impaired, or use an alternative language device so the member can effectively communicate his/her needs to a Member Services representative.

Member Services representatives can answer member questions and/or direct members to appropriate resources at the Plan, including the Behavioral Health hotline. The role of the Member Services representative is to:

Conduct continuous member education on our administrative guidelines and benefits
Serve as a liaison among the Plan, you and the member
Facilitate the member’s access to care
Investigate, resolve, and respond to all member inquiries
Assist members with PCP assignments or transfers to new PCPs, if requested by members

12.12.3 Behavioral Health Hotline

Our toll-free Behavioral Health provider hotline number is 1-866-444-5155.

Our toll-free Behavioral Health member hotline numbers are available 24 hours a day, seven days a week:

MassHealth members can call 1-888-217-3501
Commonwealth Care and Commercia plansl members can call 1-877-957-5600. No referral is necessary in an emergency situation.

12.12.4 Nurse Advice Line

Members may call our toll-free Nurse Advice Line to speak with a trained registered nurse about health-related issues. The Nurse Advice Line is available to members 24 hours a day, seven days a week at 800-973-6273 (MassHealth) or 800-765-7344 (Commonwealth Care and Commercial plans). Following a set of established protocols, a registered nurse assesses a member’s symptoms, triages the member, and recommends services. This may include having the member contact his/her treating provider or PCP, administer self-treatment, and/or seek immediate help in an emergency department. We educate members that the Nurse Advice Line does not replace the member’s PCP, who provides primary care services and coordinates the member’s care.

12.12.5 New Member Materials

We provide new members with a member enrollment packet.

Our MassHealth new-member packet includes a Member Handbook.
Our Commonwealth Care members receive an Evidence of Coverage (EOC) and a Member Guide.
Our Commercial members receive an Evidence of Coverage.

New members in all products also receive information on accessing our online Provider Directory. Please note that a Health Risk Assessment form is sent to all members with their Plan ID cards.

The MassHealth Member Handbook, Commonwealth Care EOC and Commercial plans EOC include the following information:

A description of our covered services (If appropriate, MassHealth benefits are included for those members) and related copayments and other cost-sharing such as deductibles and coinsurance.
A description of the role of the PCP, and information on how members may select or change a PCP
How members can obtain information about network providers
How members can access medical/surgical and behavioral health services
How members can get prescription drugs and the copayment amounts
How members can obtain emergency services, including guidelines on when to access emergency services directly, when to use 911 services, and how to access alternatives to emergency room care
How members can obtain care and coverage when out of our service area
Toll-free numbers for our Member Services department and member Behavioral Health hotline
- Rights and responsibilities of members
- How a member can submit a complaint, grievance, or appeal of a benefit or coverage decision to the Plan

We provide members with user-friendly benefit literature in English or Spanish. In addition, at the time of enrollment we tell MassHealth and Commonwealth Care members of their right to terminate their membership in the Plan at any time.

12.12.6 Member Orientation

We make our best efforts to contact each new member by mail or by telephone to welcome him/her to the Plan and provide an orientation to our administrative guidelines, covered benefits, role of the PCP, network composition, and methods of communicating with us. We also urge new members to complete a health risk assessment (HRA), enabling us to follow up with members identified as high-risk or who may have a chronic medical condition. We refer those members to our care management staff to perform a comprehensive assessment.

Plan communication with high-risk members may include information related to:

Signs and symptoms of common diseases and complications
Early intervention strategies to avoid complications of illness
Risk-reduction strategies
Treatment options to maintain optimal functioning
Notifying a member if s/he is eligible for enrollment in a clinical program or community service based on his/her diagnosis, condition, or symptom(s)

12.12.7 Ongoing Member Communication

We maintain ongoing communication with our members as follows:

We accept and answer member inquiries through written correspondence and calls made to our Member Services department.
We mail a member newsletter to each member. The newsletter includes information related to health issues, preventive services, covered benefits, general information on the Plan, administrative guidelines, and answers to frequently asked questions.
We periodically send mailings to members regarding important clinical and administrative issues that are not included in the member newsletter. Additional copies of member ID cards, Evidences of Coverage, Member Handbooks and printed Provider Directories are also mailed to members, upon request.
We contact members to conduct health risk assessments (HRAs), verify member information related to Plan membership or PCP assignment, investigate member complaints, follow up on member questions, process appeals, and/or coordinate care management activities.
At least annually, we provide members with an explanation of physician compensation arrangements through a newsletter or other member material.
We contact members to conduct member satisfaction surveys.

Providers