One Care: MassHealth Plus Medicare
Integrated Care for Dual Eligible Adults Age 21-64
What is One Care?
One Care is a new health care option for Massachusetts adults, age 21-64, who are eligible for both MassHealth and Medicare (dual eligible). The One Care target population includes non-elderly adults with physical disabilities, developmental disabilities, serious mental illness, and substance abuse disorders.
One Care combines funding from MassHealth and Medicare in an integrated managed care system. The goal of One Care is to provide higher qualify care for dual eligible adults under age 65 at a lower cost than MassHealth and Medicare provide separately.
One Care offers a broad range of medical and behavioral health services, long-term services and supports, and community-based services, all in a single individualized program. One Care participants receive services by joining One Care plans. Each One Care plan has a network of health professionals to provide care for its members. Hospitals, specialists, and community agencies provide additional services.
No one is required to join One Care. Dual eligibles who qualify for One Care can choose to self-enroll in One Care, opt out of One Care, or wait to be auto-enrolled in One Care. Anyone who enrolls in a One Care plan may opt out and use MassHealth and Medicare providers on a fee-for-service basis at any time.
Am I Eligible?
One Care is for adults who:
• are age 21 through 64 at the time of enrollment
• are eligible for MassHealth Standard or CommonHealth
• are enrolled in Medicare Parts A and B and eligible for Part D
• do not have access to other public or private health insurance that meets basic benefit level requirements
• live in the service area of a One Care plan
• agree to receive all covered medical and behavioral health services and long-term services and supports from a One Care plan
Note: One Care will not currently enroll people who have joined PACE or an HCBS Waiver program.
What Benefits Will I Get?
When you enroll in One Care, you will get:
• all of the health care and support services currently covered by MassHealth and by Medicare:
• medical care
• behavioral health care
• prescription drugs
• dental services
• primary care provider and care team who work with you to develop an individualized care plan
• person-centered and appropriate care in the least restrictive care setting
• a Care Coordinator to help you get all of the health care services you need
• an Independent Living Long-Term Services and Supports Coordinator (LTS Coordinator) if needed
• simplified contact system for customer service, prior authorizations, appeals, etc.
• one health insurance card for all services
In addition if you are eligible you will get:
• Long-term services and supports (LTSS) includes a wide range of things that help you live more independently in your home and community, such as mobility and communications equipment and devices, home health aides and other assistants, and day programs
• Diversionary Behavioral Health Services, if included in your care plan includes outpatient and community treatment programs and services. If you have behavioral health needs, these services may help you stay out of a hospital or facility.
• Community-based services, if included in your care plan, may include care transitions assistance, community health workers, day services, home care services, medication management, home modifications, peer support, respite care, and transportation. These services may help you stay at home instead of going to a hospital or nursing facility.
If you join One Care, you will get all of your covered services from your One Care plan's network of providers and authorized community partners. You will not be covered for services from other doctors or health care providers, except in an emergency.
You can end your enrollment and go back to regular MassHealth and Medicare dual coverage at any time if you decide One Care is not right for you.
How do I apply?
- MassHealth Customer Service
TTY: 1-800-497-4648 (for people who are deaf, hard of hearing, or speech disabled)
- SHINE counselors can work with you and your caregivers to help you understand your options. They are trained to assist people who have Medicare and MassHealth and will provide impartial information about your health insurance options. A counselor can work with you in person, by phone, or through e-mail.
Monday – Friday 9 a.m.-5 p.m.
TTY: 1-800-872-0166 (for people who are deaf, hard of hearing, or speech disabled)
One Care Health Plans
The two One Care plans that are currently available are:
• Commonwealth Care Alliance (CCA): (This plan is available in all 14 towns within BayPath's service area)
• Tufts-Network Health: (In BayPath's service area this plan is only available in Southborough, Westborough, and Northborough)
How Do I Use My Benefits?
If you decide to enroll in a One Care plan, you must choose a primary care provider from your plan's network. Your primary care provider will evaluate your medical and behavioral health.
You and your primary care provider, along with your Care Coordinator and care team, will decide on a care plan that works best for you. You will get the medical, behavioral, dental, long-term services and supports, and community-based services that are part of your individual care plan.
When you enroll in One Care, there will be no immediate changes in your care. You will have a transition period to make sure that the change from MassHealth / Medicare dual coverage to One Care does not cause any problems with your care.
Remember that you are not required to join One Care and you may opt out and go back to regular MassHealth and Medicare dual coverage at any time.
For more information call BayPath at 508-573-7200.