Exceptions to the rules: employer-sponsored insurance and eligibility

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April 9, 2008 - 4:43pm - Keith Barry - Manet Community Health Center- Quincy and Hull


Recently, I have seen an increase in the number of Exceptions Forms sent to Commonwealth Care applicants who the state believes have access to employer-sponsored insurance. These clients are not eligible for Commonwealth Care until they return the Form – but it can be hard to understand what makes the state mail it to these individuals in the first place. These are a few examples of cases I’ve seen, as an Outreach Worker at Manet Community Health Center in Quincy and Hull:

CASE #1

On April 3, 2008, I received in the mail an Exceptions Form for a man who worked part-time as a long-haul delivery driver but mostly did odd-jobs and got paid in cash. He did not file taxes, and his income was self-reported as $500 weekly, working 80 hours per week. He considered himself a day (and night!) laborer. On his Virtual Gateway application, which I completed, I indicated that he was not offered insurance and had not been offered insurance within the past six months.

I called the Taunton MEC, and the MEC employee updated his case and made him eligible for Commonwealth Care. I mentioned that I was curious about the number of Exceptions Forms I’d received. She told me that there was a recent mass mailing of Exceptions Forms sent regardless of whether applicants indicated their employer offered them insurance, and this mailing was intended to decrease the number of enrollees who were offered private insurance. She also informed me that self-employed people should not be on Commonwealth Care, but instead should sign up for the Insurance Partnership.

UPDATE: A follow-up call to the Taunton MEC assured me that the information from the previous MEC worker was incorrect. The reason for the increase in Exceptions Forms has to do with the new Federal Poverty Level (FPL) guidelines going into effect on April 1. According to this MEC worker, implementing the new FPL triggered a system-wide audit of all applications, including those where the applicant had not indicated whether or not they were offered employer-sponsored insurance.

CASE #2

Several months earlier, I’d spoken with a self-employed client who filled out her ERV but left blank the sections she did not understand. Weeks later, she was told her Commonwealth Care was ending because she indicated on her ERV that her employer offered her insurance, even though the client had simply left that section blank. When I called the Taunton MEC, the MEC employee said that I should “expect a lot more exceptions forms” because “anyone who didn’t specifically check off on their ERV that they were NOT offered insurance by their employer would be considered to have been offered insurance.”

CASE #3

At a health fair last summer, I encountered a 45 year-old single woman who worked at a “big box” retailer on the South Shore. Even though she worked as many as 39 hours a week, her employer classified her as “part time” and did not offer her insurance. She had some chronic illnesses, yet hadn’t been to a doctor in years because of her lack of insurance. She was skeptical at first, but thrilled when she was able to enroll in a Commonwealth Care plan.

Fast forward to March of 2008 when I got a dreaded message on my voicemail: The applicant from the previous summer was panicking because MassHealth had sent her a letter saying that her coverage was ending March 31st, and she already had a surgery scheduled for the end of April. I checked My Account Page and found that she’d been sent an Exceptions Form, meaning that at some point, MassHealth discovered or assumed that her employer offered her insurance. When I inquired, she told me that she’d asked her employer if they offered health insurance and was told “yes,” which she in turn reported to MassHealth.

I met the enrollee at her workplace and spoke with her human resources manager, who informed me that, yes; they offered a Limited Benefit Medical Plan to all part-time employees. The plan was entirely paid for by the employee, featured no prescription coverage, and had a yearly maximum benefit of $1000 – a plan so limited that employees would still be eligible for Commonwealth Care. After some discussion, the manager was horrified to learn that he had told several part-time employees that they were offered health insurance, and that as a result the state considered them ineligible for state-sponsored programs. This woman is still on Commonwealth Care, and a lot of her co-workers will be joining her in the near future.

I am very curious to hear if anyone else has encountered situations like these, and if anyone else has a case similar to #1 where an applicant was denied due to an Exceptions Notice even though on their application they indicated they were not offered insurance. Does anybody know why the MEC would assume that they have insurance? Is this a fluke?

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