Primary Care Clinician Plan

PRIMARY CARE CLINICIAN PLAN

MEMBER HANDBOOK

Helping you with your health-plan benefits.

1-800-841-2900

TTY: 1-800-497-4648

These extra pages are the Covered Services List for your coverage type.

This is a list of the services and benefits MassHealth covers.

Please keep in mind that MassHealth services and benefits change from

time to time. This Covered Services List is for your general information

only. MassHealth’s regulations govern the services and benefits available to

you. To access MassHealth’s regulations:

go to MassHealth’s website at or

call MassHealth Customer Service at 1-800-841-2900

(TTY: 1-800-497-4648 for people with partial or total hearing loss).

Check MassHealth regulations for more information about services and

benefits covered by MassHealth, or call MassHealth Customer Service to

ask questions. Remember to show your MassHealth ID card to receive your

benefits and services.

Table of Contents

Welcome!3

Your MassHealth PCC plan membership 6

What is MassHealth?6

What is the PCC Plan?6

PCC Plan Provider Network6

PCC Plan behavioral health provider network6

Out-of-Network Services7

Medical services7

Behavioral health services7

When you travel7

Keeping your providers up to date8

Keeping MassHealth up to date8

Reporting address, phone number, and income changes8

Other health insurance8

Birth of a baby8

If you receive benefits other thanMassHealth9

Changing your health plan9

You must qualify for MassHealth to be in the PCC Plan9

Your MassHealth ID card10

MassHealth will send you a MassHealth ID card10

Lost your MassHealth ID card?10

Your benefits11

How to get benefits11

Transportation11

Copayments11

Non-pharmacy copayment cap12

If you can’t pay the copayment12

Specialty care and referrals 12

Which services do not need a referral?13

Prior authorization13

PA from MassHealth for medical services, medical equipment, pharmacy, and transportation. 13

Preadmission screening by MassHealth for certain hospital stays.14

PA from MBHP for behavioral health (mental health and substance use disorder) services 14

If you get a bill for services15

Your Primary Care Clinician (PCC)16

What is a primary care clinician (PCC)?16

Providers who are PCCs16

Your first appointment with your new PCC16

Call your PCC first when you’re sick, unless you think it’s an emergency 18

Specialty care and referrals 18

Changing your PCC18

If a PCC requests to disenroll you from his or her practice18

Your health care19

Emergencies and urgent care19

Getting an appointment when you need one20

Staying healthy21

Pharmacy coverage22

Pharmacy copayments 22

Pharmacy copayment cap22

If you can’t pay the copayment23

Finding behavioral health (mental health and substance use disorder) providers 23

7. Oral health/dental services24

Services for children (members underage 21)24

Services for adults (members aged 21and older)24

How to find a dentist25

8. Behavioral health care 26

Your behavioral health (mental health and substance use disorder services) coverage 26

9. Integrated Care Management Services27

Integrated Care Management Program (ICMP) Care Management Program27

Community Case Management (CCM) 27

10. Pregnancy and family planning services29

Pregnancy care29

Make an appointment with your PCC,

obstetrician/gynecologist (OB/GYN), or nurse midwife29

Pregnancy and oral health29

Your new baby30

Family planning30

11. Services for children31

Preventive and well-child care for all children31

Preventive Pediatric Health-Care Screening and Diagnosis (PPHSD) services for members enrolled in MassHealth

Prenatal or Family Assistance32

Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services for members enrolled in MassHealth

Standard or CommonHealth32

Early-intervention services for children with growth or developmental problems 33

12. Advance directives34

13. Member rights 35

14. Appeals and grievances 37

Naming a representative for your grievance or appeal37

What do you do if you do not speak or read English?37

The grievance process37

How to file a behavioral health grievance 38

Filing a grievance about MassHealthservices39

The MBHP internal appeals process. . 40

How to file an MBHP internal appeal. .40

Information you need to file an MBHPinternal appeal41

Continuing benefits during your MBHP internal appeal41

After you file an MBHP internal appeal42

Getting a decision on your MBHP internal appeal42

An expedited (fast) MBHP internal appeal42

Extending MBHP internal appeal timeframes.42

Approval of your MBHP internal appeal43

Denial of your MBHP internal appeal43

Dismissal of your MBHP internal appeal43

The Board of Hearings appeals process44

Continuing benefits during your fair hearing at the Board of Hearings 45

After you file a Board of Hearings appeal45

15. Notice of Privacy Practices46

Notes

1. Welcome!

Welcome to the MassHealth Primary Care Clinician Plan (the PCC Plan). We’re pleased to

have you as a member.

This Handbook, along with the Covered Services List, will help you understand your benefits

and services as a PCC Plan member. It will also tell you how to call us if you have any

questions.

Because this Handbook contains important information, please keep it in a place where you

can find it when you need it.

These are the important things you should know as a PCC Plan Member.

This Handbook is about the benefits and services you receive because you are

a MassHealth member enrolled in the Primary Care Clinician (PCC) Plan.

These services include emergency services, medical services, vision care services, behavioral

health (mental health and substance use disorder) services, pharmacy services, and dental

services.

Please note that you will receive your behavioral health services through the Massachusetts

Behavioral Health Partnership (MBHP). MBHP is MassHealth’s behavioral health services

contractor. There are a few important differences between the services you get directly from

MassHealth and the behavioral health services you get from MBHP, especially concerning

appeals and grievances. This Handbook explains those differences.

Read more about covered benefits and services, including behavioral health

and dental services, later in this Handbook.

Call us with your questions or changes.

Call the MassHealth Customer Service Center Monday through Friday, 8:00 a.m. to 5:00 p.m.

The call is free.

Call us

¦ if you have questions about MassHealth;

¦ if you have questions about your PCC Plan coverage or benefits;

if you have questions about Early and Periodic Screening, Diagnosis and

Treatment (EPSDT) services for children under 21 (see page 32 to read

more about EPSDT);

¦ if you want to change your Primary Care Clinician (PCC);

¦ if you want to change your health plan;

¦ if you need a new MassHealth ID card;

¦ if you move or change your phone number;

¦ if your employment status changes;

¦ if you’re pregnant or have a baby;

¦ if you’d like help reading any material you get from MassHealth;

if you want to ask for Spanish versions of information you get from the

PCC Plan; or

if you want to speak with someone who speaks Spanish or another

language.

Call MBHP with behavioral health (mental health and substance use disorder)

questions.

Call MBHP 24 hours a day if you have questions about MBHP or

behavioral health services. The call is free.

¦ Call MBHP

if you have questions about your behavioral health (mental health and

substance use disorder) services or benefits;

if you want more information about how to get these services or find a provider;

to ask for help reading any material you get from MBHP;

to ask for Spanish versions of information you get from MBHP; or

to speak with someone who speaks Spanish or another language.

4. You still have MassHealth when you join us.

As a PCC Plan member, you keep all your MassHealth coverage and benefits.

You can be enrolled in the PCC Plan for as long as you’re qualified and in

MassHealth Managed Care.

As long as you still qualify and are in MassHealth managed care you can be covered by

the PCC Plan. Call the MassHealth Customer Service Center if you have questions about

managed care.

6. You have a Primary Care Clinician (PCC).

Your PCC will take care of most of your health needs. Your PCC can be either a doctor or a

nurse practitioner. You can change your PCC at any time. If you want to change your PCC,

call the MassHealth Customer Service Center.

7. The PCC Plan has providers and hospitals throughout the state.

You can find PCC Plan providers (such as medical care providers, medical-care specialists,

behavioral health providers, and hospitals) all over Massachusetts. For information, call the

MassHealth Customer Service Center.

MBHP has behavioral health (mental health and substance use disorder) providers

throughout the state, too. For information, call MBHP at 1-800-495-0086.

8. Present Your MassHealth ID card when you need services.

You can use your MassHealth ID card to get PCC Plan services, such as health care and

prescriptions. This includes the services you get from MBHP. Carry your MassHealth ID card

with you always. If you lose your ID card, call MassHealth Customer Service.

9. Let us know when your phone number or address changes.

Call MassHealth Customer Service to tell us if you move or change your phone number.

If you do not notify us of changes, you may not receive important notifications from

MassHealth.

10. You have pharmacy coverage.

PCC Plan members can get medicines at pharmacies in Massachusetts that work with

MassHealth. Call MassHealth Customer Service to find the pharmacy closest to you.

Read more about pharmacy coverage later in this Handbook.

11. You can receive emergency care for medical and behavioral health (mental

health and substance use disorder) emergencies.

If you have a medical or behavioral health emergency, get care right away! Call 911, or if it’s a

behavioral health emergency, you may also contact the Emergency Services Program (ESP) in

your area. Call the statewide, toll-free ESP number at 1-877-382-1609 to get the number for

your local ESP, 24 hours a day.

12. Some services require referrals or prior authorization or both.

Some covered services may need a referral or prior authorization (PA) or both. However,

many covered services, such as emergency health care, obstetric (pregnancy) services, dental,

and family planning services, do not require a referral or PA. Behavioral health services do

not require a referral, although some behavioral health services require PA. Read more about

referrals and PA later in this Handbook.

2. Your MassHealth PCC plan membership

What is MassHealth?

The Medicaid program in Massachusetts is called the MassHealth program. The Executive

Office of Health and Human Services (EOHHS) runs this program.

What is the PCC Plan?

The Primary Care Clinician (PCC) Plan is a managed-care health plan for MassHealth

members throughout Massachusetts.

Each PCC Plan member must choose a doctor or nurse practitioner to be a primary care clinician (PCC). If you do not choose a PCC, we will choose one for you. It’s better if you make the choice!

You can see your PCC when you need a checkup or are sick. Your PCC will get to know your health needs, and help you get other health services if you need them. Read more about PCCs later in this Handbook.

PCC Plan Provider Network

The PCC Plan provider network includes doctors, nurse practitioners, hospitals, pharmacies, and other health care providers who are MassHealth providers.

Make sure you check to see if a provider accepts MassHealth before going for health care.

If you go to a provider who does not accept MassHealth, MassHealth will not pay for the services unless it is an emergency.

If you need help finding a MassHealth PCC Plan provider in your area, please call MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648 for people who are deaf, hard of hearing, or speech disabled).

PCC Plan behavioral health provider network

As a PCC Plan member, you can get behavioral health (mental health and substance use disorder) services from the Massachusetts Behavioral Health Partnership (MBHP). MBHP is MassHealth’s behavioral health services contractor. MBHP has a large network of mental health and substance-use disorder providers and hospitals throughout the state.

Use your MassHealth ID card to get behavioral health services from any MBHP provider. You

do not need a referral to see any of MBHP’s providers.

All you need to do is choose a behavioral health provider from the MBHP Provider Directory.

You can find the directory online at Just click “Find a Provider” on the home page. If you would like a printed copy of the Provider Directory, please call MBHP at 1-800-495-0086.

After you choose a provider from the directory, please call MBHP to make sure your provider still works with MBHP. This directory is updated weekly, but providers may change from time to time.

Although you do not need a referral to see any MBHP provider, some covered services may need PA. For more information about PA, see page 13.

Out-of-Network Services

Medical services

The PCC Plan will not pay for services delivered by a provider who is not a MassHealth provider unless it is an emergency.

You can get care for emergencies from any provider. For more information about emergencies, see pages 19-20. If you have an emergency, get care right away!

Behavioral health services

MBHP will not pay for services provided by a behavioral health provider who is not in the

network unless:

¦ it is an emergency; or

¦ the MBHP network cannot provide those services.

You can get care for behavioral health emergencies from any behavioral health provider.

For more information about behavioral health emergencies, see pages 19-20. If you have a

behavioral health emergency, get care right away!

If MBHP’s network cannot provide the services, MBHP will cover the out-of-network services

until the network can provide them.

Call MBHP if you have questions about out-of-network behavioral health services.

When you travel

The PCC Plan will pay for you to see an out-of-state provider for medical care only if:

¦ you have an emergency; or

¦ your health would be at risk if you had to travel home.

Keeping your providers up to date

We want to make sure you get the right services at the right time. Tell your providers about:

¦ all the health care you are getting;

¦ the medicine you are taking (both prescription and over-the-counter medications); and

¦ any health problems you may have.

Keeping MassHealth up to date

It is important to tell MassHealth as soon as possible about changes, such as a new address

or phone number, other health insurance, the birth of a baby and other family changes, or a

change in your income.

Reporting address, phone number, and income changes

If MassHealth has your correct address, we can send you information about benefits and

services. If we have the wrong address, we can’t send you mail and we can’t tell you when it’s

time to renew your MassHealth. You could lose your benefits. To tell MassHealth about your

new address and phone number, call the MassHealth Customer Service Center. Also call this

number to report changes in your income.

Other health insurance

If you have other health insurance, like Medicare, veterans’ benefits, or health insurance

through your job or a family member’s job, or if you have a chance to get other insurance,

call the MassHealth Customer Service Center. MassHealth may help you pay for the other

insurance.

Birth of a baby

If you are expecting a baby, call the MassHealth Customer Service to find a doctor for your

baby before the baby is born.

After you have your baby, call the MassHealth Enrollment Center to tell

them that you had your baby and help you enroll your baby in MassHealth.

Once your baby is enrolled in MassHealth, call the MassHealth Customer

Service Center to enroll your baby with a doctor of your choice.

If you receive benefits other than MassHealth

You should also report changes if you receive these additional benefits.

If you get Transitional Assistance for Dependent Children (TAFDC) or

Emergency Aid for Elderly, Disabled or Children (EAEDC), call your local

Department of Transitional Assistance (DTA) office at 1-800-445-6604

(TTY: 1-888-448-7695).

If you get Supplemental Security Income (SSI) or Social Security Disability

Income (SSDI), call your nearest Social Security Administration (SSA)

office at 1-800-772-1213 (TTY: 1-800-325-0778).

If you get assistance from the Massachusetts Commission for the Blind

(MCB), call the MCB at 1-800-392-6450 (TDD: 1-800-392-6556).

Changing your health plan

Most MassHealth members can change their health plan at any time. To find out about

changing, call the MassHealth Customer Service Center and say, “I would like to change my

health plan.”

The MassHealth Customer Service Center can:

¦ give you information about other health plans in your area;

¦ change your health plan while you are on the phone; and

¦ tell you when you can start getting health care from your new health plan.

In general, you must enroll in a health plan that is offered in the service area where you

live. You can call the MassHealth Customer Service Center to find out which health plans

are offered in your service area. There are certain cases where you can choose a health plan

that is not available in your service area. For more information about these cases, call the

MassHealth Customer Service Center.

You must qualify for MassHealth to be in the PCC Plan

You cannot continue to be in the PCC Plan if you no longer qualify for MassHealth.

3. Your MassHealth ID card

MassHealth will send you a MassHealth ID card

MassHealth will send you a MassHealth ID card that looks like the one below. Carry it with

you, and use it to get your PCC Plan services, including services from MBHP.

This is a sample of the front and back of a MassHealth ID card.

Remember to carry your MassHealth ID card and show it, or any other health insurance card

you may have, to get health care services or medicine.