Maximizing the Use of Private by Medicaid Recipients

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Jo Anne Bayliss
Child Service Coordinator, Massachusetts Department of Mental Retardation

Nancy Kealey
Assistant Director, Premium Assistance Programs, Massachusetts Office of Medicaid

The Massachusetts Medicaid program, known as MassHealth, provides direct health care coverage to eligible, uninsured children and adults as well as assistance with premium payments for recipients who are enrolled in or have access to private health insurance plans. The University of Massachusetts Medical School, through an Interagency Service Agreement with the Massachusetts Executive Office of Health and Human Services, administers the Revenue Operations Program, which strives to reduce the net state cost for certain Health and Human Service programs. The MassHealth Standard and CommonHealth Premium Assistance (MSCPA) program and the Enhanced Coordination of Benefits (ECOB) program together seek to ensure MassHealth’s status as payor of last resort.

The MSCPA program works in partnership with the ECOB program to identify and maximize the use of third party resources available to ECOB’s target group of MassHealth recipients in need of medically complex, high-cost services. Working in collaboration with MSCPA program staff, ECOB staff can offer the benefit of premium assistance to many MassHealth recipients who have access to commercial coverage. ECOB staff work one-on-one with recipients and their families, commercial insurers, and current or former employers to identify, purchase, and utilize private sector health insurance. ECOB staff also work on-site at hospitals and trauma centers throughout the state to coordinate commercial health insurance benefits and services with MassHealth benefits and services.

The availability of private sector insurance enables MassHealth recipients to receive comprehensive health care packages with service options, and enables hospitals to bill higher paying, commercial insurers for inpatient and follow-up services, with the expenses effectively shared by the public and private sectors.

During FY04, the MSCPA program implemented an automated referral system to target for investigation all MassHealth recipients who have potential access to employersponsored insurance coverage, including COBRA plans. Verified insurance data are posted to the state’s claim data bank to avoid or share future state health care costs with private sector health insurers and to take recovery actions on paid claims for which the state is not liable. For FY04, the program saved the Commonwealth more than $12 million.

Approximately one-quarter of ECOB cost savings can be attributed to the availability of premium assistance. Since its inception in 1999, the ECOB program has saved the Commonwealth in excess of $32 million.

Systematically expanding what is being done through the MSCPA and ECOB programs to all groups of Mass- Health recipients who have access to private health insurance would save government money, provide financial reimbursement to families who would benefit from it, and expand access to private health insurance to low-income and disabled citizens. For example, the health care costs of many adults with disabilities can be shifted to private health insurance, while providing financial reimbursement to their families and expanding health insurance coverage for these consumers. An added benefit is that reimbursement from MSCPA may enable parents of children and adults with disabilities who do not have any health insurance to gain access to it.

About the Authors

Jo Anne Bayliss has been a child service coordinator in Maine and Massachusetts for 19 years. Her professional interests include research-based practices as well as benefits and entitlements for children with developmental disabilities. She completed a study on critical core competencies for child service coordinators in 1997.

Nancy Kealey is the Assistant Director of Premium Assistance Programs in the Office of Medicaid, a division of the Massachusetts Executive Office of Health and Human Services.