Section 13: BMC HealthNet Plan Product Information

This section of the Provider Manual describes the products BMC HealthNet Plan offers and some information specific to those products/plans. For more information on the benefits available under each plan, please visit the Members section of bmchp.org.

13.1 MassHealth

Any MassHealth member who is eligible to enroll in a managed care organization (MCO) may enroll in BMC HealthNet Plan. BMC HealthNet Plan members have a wide range of health care services available through BMC HealthNet Plan as well as services covered by MassHealth. Services covered by MassHealth are known as “wraparound” or “non-MCO” benefits. To determine coverage for benefits, please refer to the MassHealth Covered Services List as well as the MassHealth Member Handbook available on our website, in the Members section, at bmchp.org.

• BMC HealthNet Plan offers four MassHealth plans: Standard, Family Assistance, Basic and Essential.
• Members must select a PCP to direct and manage their care.
• Most services are not subject to cost-sharing except for prescription and over-the-counter drugs for members age 19 and older and in certain circumstances such as when a member is enrolled in hospice care.
• Referral requirements must be followed for BMC HealthNet Plan coverage as well as the wraparound/non-MCO benefit coverage.
• Some services will require prior authorization.
  • For services covered by BMC HealthNet Plan, you will need to follow the process for obtaining prior authorization described in section 3 of this manual.
  • For wraparound/non-MCO benefits, you must contact MassHealth to verify benefits and eligibility and obtain pre-authorization for services. You must bill MassHealth directly for such services.
    • Examples of wraparound/non-MCO benefits may include, but are not limited to routine dental services, Home Assessments and Participation in Team Meetings (Chapter 766), Keep Teens Healthy and coverage for eyeglasses, contact lenses and other visual aids.
• Some services are not covered by either BMC HealthNet Plan or MassHealth. These include, but are not limited to:
  • cosmetic services, devices, drugs and surgery except when they are prior authorized by the Plan and are performed to correct or repair damage following an injury, illness or congenital deformity causing functional impairment, and/or to perform mammoplasty following mastectomy;
  • diagnosis and treatment for infertility, reversal of voluntary sterilization and services or fees related to achieving pregnancy through a surrogate;
  • over-the-counter prescription drugs not listed on the Plan formulary and/or the provider has not given a prescription for the drug that meets all legal requirements for a prescription;
    • experimental or investigational drugs;
    • drugs not approved by the FDA;
    • dietary and nutritional supplements; and
    • drugs that have been deemed less-than-effective by the U.S. Food and Drug Administration

13.2 Commonwealth Care

Massachusetts residents may be eligible to enroll in state-subsidized Commonwealth Care plans through the Commonwealth Connector Authority (“Connector”). Applicants must meet Connector eligibility requirements to enroll. Applicants should contact the Connector for more information. To determine coverage for benefits, please refer to the Commonwealth Care Evidence of Coverage and the appropriate Plan Type available on our website in the Members section, at bmchp.org.

Some highlights of the Commonwealth Care plans are:

• BMC HealthNet Plan offers three Commonwealth Care plans: Plan Type I, II and III.
• Members must select a PCP who will direct and manage their care.
• Most Plan Type I services are not subject to cost-sharing except for prescription and over-the-counter drugs.
• Preventive services, as defined by the Patient Protection and Affordable Care Act (PPACA), are covered with no cost-sharing. For more information about which preventive services are included, see the Preventive Health Services section at bmchp.org or the federal government’s website at healthcare.gov.
• The Connector may waive copayments under Plan Type I due to a finding of extreme financial hardship.
• BMC HealthNet Plan covers the cost of screening by an emergency facility but does not cover the cost of non-emergency care provided to a member at an emergency facility.
• Some services will require prior authorization.
  • For services covered by BMC HealthNet Plan, follow the process for obtaining prior authorization described in section 3 of this manual.
• Some services are not covered by BMC HealthNet Plan. These include but are not limited to:
  • cosmetic services, devices, drugs and surgery except when they are prior authorized by the Plan and are performed to correct or repair damage following an injury, illness or congenital deformity causing functional impairment, and/or to perform mammoplasty following mastectomy;
  • diagnosis and treatment for infertility, reversal of voluntary sterilization and services or fees related to achieving pregnancy through a surrogate;
  • over-the-counter prescription drugs not listed on the Plan formulary and/or the provider has not given a prescription for the drug that meets all legal requirements for a prescription;
    • experimental or investigational drugs;
    • drugs not approved by the FDA;
    • dietary and nutritional supplements; and
    • drugs that have been deemed less-than-effective by the U.S. Food and Drug Administration

13.3 Commercial Plans at BMC HealthNet Plan

BMC HealthNet Plan offers an HMO Commercial product to individuals (and their enrolled family members) and employer groups. All of our Commercial plans meet Massachusetts minimum creditable coverage standards and cover all mandated benefits.

BMC HealthNet Plan currently offers six HMO Commercial plans, although additional plans may be offered in the future. These plans are offered through our BMC HealthNet Plan Select (provider) network. Not all providers who participate in our MassHealth and Commonwealth Care provider networks participate in the Select network. If you have any questions about whether you participate in the Select network for our Commercial plans, please call your BMC HealthNet Plan Provider Relations representative. Members enrolled in our Commercial plans must obtain all their covered health care services from our Select network providers – except in emergencies or when authorized in advance by BMC HealthNet Plan.

When made available to individuals and small groups through the Connector, our Commercial plans are referred to as Commonwealth Choice plans. Commonwealth Choice member ID cards will have both the BMC HealthNet Plan and Connector logos. When made available directly from BMC HealthNet Plan to groups, our Commercial plans are referred to as Employer Choice plans. Employer Choice plans will have just the BMC HealthNet Plan logo.

Each Commercial plan requires members to choose a primary care provider (PCP) who is responsible for managing or providing the member’s care. Please go to our website, bmchp.org, or the Connector’s website, MAHealthConnector.org, for more information on these Commercial plans.

Most covered services are subject to member cost-sharing methods: copayments, deductibles, and/or coinsurance. Please refer to the Schedules of Benefits at bmchp.org for specific cost-sharing information related to the particular Commercial plan in which the member is enrolled.

• Office visit copayments may vary based on whether the care is provided by a PCP or specialist.
• In the course of receiving certain outpatient services (which may or may not be subject to cost-sharing), a member may also receive other covered services that require separate cost-sharing. (For example, during a preventive health services office visit (no cost-sharing), a member may have a lab test that does require cost-sharing.)
• Copayments are payable at the time of the visit.
• Providers should not bill members for coinsurance and/or deductibles until the claim has processed. This will ensure that members are billed accurately. The Remittance Advice will reflect the member’s cost-share amount.
  • Balance billing of covered services is not allowed – except for applicable copayments, coinsurance and deductibles.
• Preventive services, as defined by the Patient Protection and Affordable Care Act (PPACA), are covered with no cost-sharing. For more information about which preventive services are included, see the Preventive Health Services section at bmchp.org or the federal government’s website at healthcare.gov.
• Some services will require prior authorization. You will need to follow the process for obtaining prior authorization described in this manual.
• For newborns, BMC HealthNet Plan covers routine nursery charges and well newborn care. The newborn must be enrolled in the Plan within 30 days of date of birth in order for the Plan to cover any other medically necessary services rendered to the newborn.
• Some services are not covered by the Plan. These include:
  • services that are not medically necessary;
  • cosmetic services, devices, drugs and surgery except when they are prior authorized by the Plan and are performed to correct or repair damage following an injury, illness or congenital deformity causing functional impairment, and/or to perform mammoplasty following mastectomy;
  • reversal of voluntary sterilization and services or fees related to achieving pregnancy through a surrogate;
  • over-the-counter prescription drugs;
  • drugs not approved by the FDA;
  • dietary and nutritional supplements; and
  • drugs that have been deemed less-than-effective by the U.S. Food and Drug Administration

13.3.1 Commercial Plans - Cost-Sharing Terms

Listed below are cost-sharing terms and their definitions applicable to the Commercial product:

• Deductible: The specific dollar amount a member may pay for certain covered services in a benefit year before the Plan is obligated to pay for those covered services. Once a member meets his/her deductible, he/she pays either nothing, or the applicable copayment or coinsurance for those covered services for the remainder of the benefit year. Deductible amounts are in the member’s Schedule of Benefits posted on our website at bmchp.org.
• Copayment: A fixed amount a member may pay for certain covered services. Copayments are paid directly to the provider at the time the member receives care (unless arranged otherwise). Copayment amounts are in the member’s Schedule of Benefits posted on our web site at bmchp.org.
• Coinsurance: The percentage of costs a member may pay for certain covered services. Coinsurance amounts are in the member’s Schedule of Benefits posted on our web site at bmchp.org.
• Out-of-Pocket Maximum: This is the maximum amount of cost- sharing a member is required to pay in a benefit year for most covered services. Out-of-pocket maximum amounts, if any, are in the member’s Schedule of Benefits posted on our web site at bmchp.org.

13.4 Services Managed by Outside Vendors

Some of the services provided to BMC HealthNet Plan MassHealth, Commonwealth Care and Commercial plans members are managed by outside vendors. Examples of these are:

• Outpatient pharmacy services are managed by informedRx. See section 3.2.4. For information on our prior authorization requirements, members may:
  • Contact the Member Services department
  • Visit the Pharmacy page at bmchp.org
  • Contact informedRx (Customer Service Hours of Operation: Available 24 hours, 7 days a week.):
    informedRx
    2441 Warrenville Road
    Suite 610
    Lisle, IL 60532
    Telephone: 1- 800-227-7269
    Website: myinformedrx.com
• Mental health and substance abuse services are managed by Beacon Health Strategies, LLC (Beacon). See section 3.2.4 for information on our prior authorization requirements. Members may:
  • Call the Plan’s toll-free mental health/substance abuse telephone line – staffed by Beacon – at 888-217-3501 (MassHealth members) or 877-957-5600 (Commonwealth Care and Commercial members) for help finding a network provider 24 hours a day.
  • Visit Beacon’s website, beaconhealthstrategies.com, or follow the link on our website’s Find a Provider page to look up network providers.
• Durable medical equipment, including prosthetics, orthotics, medical supplies, medical formulas, oxygen and respiratory equipment and low protein foods are generally managed by Northwood, Inc (NW). See section 3.2.4 for more information regarding when and how to contact Northwood.
• Advanced elective radiology, including Magnetic Resonance Imaging (MRI/MRA), Computed Tomography (CT), Positron Emission Tomography (PET), and Nuclear Medicine/Myocardial Perfusion Imaging (NCM/MPI) studies are managed by MedSolutions, Inc. See section 3.2.4 for more information regarding when and how to contact MedSolutions, Inc.
• Preventive dental services covered under BMC HealthNet Plan’s Commercial plans are managed by Delta Dental of Massachusetts. To find Delta Dental-participating dentists, or for questions about this benefit, members may:
  • Visit our Find a Provider page at bmchp.org
  • Contact BMC HealthNet Plan’s Member Services department
  • Call Delta Dental at 1-800-872-0500