MassHealth, out of network providers, other insurances, and self pay
June 12, 2022 9:46 AM Subscribe
I've heard about some odd scenarios that supposedly happen when someone has MassHealth (the Medicaid in Massachusetts) and I'd like to get some clarification/pointers to written laws so I can understand how they work.
Specific scenarios I have heard about and would like to verify/understand in greater detail:
1) Someone has MassHealth (which provides some dental coverage) as well as an additional plan that covers dental. Goes to a dentist who is in-network with both MassHealth and the other plan. Is told by the dental practice that they cannot become a patient there because of the MassHealth. (I believe this practice is no longer taking *new* MassHealth patients, which seems common. However this person did have other separate insurance that the practice takes.)
2) A primary care practice takes one specific MassHealth plan but does not take any others. They are (supposedly) per some law unable to see a patient that has a different MassHealth plan (for which the office is not in-network) even if that patient wanted to and agreed to pay out of pocket.
I suspect, but am not sure, that this might have something to do with laws about balance billing MassHealth patients--either in reality or in someone's misunderstanding of them at some point. What I would like to understand (in addition to whether these scenarios have been described to me accurately) how this plays out in more scenarios:
If the person in example 1 went to a dentist who does NOT take MassHealth but does take their second insurance, would this same thing have happened?
And more similarly to example 2, can MassHealth patients pay out of pocket to see specialists who take MassHealth but don't take their specific MassHealth plan?
What about therapists?
What about paying out of pocket to see a therapist who is officially in-network for MassHealth but is no longer accepting new clients except for self-pay clients? Can that therapist take cash from people who have MassHealth? If they officially cannot, is it something that just happens anyway, ie patient doesn't disclose that they have any insurance at all and just pays out of pocket from the get-go?
I would really really like to stress that I'm only interested in hearing from people who have specific experience with MassHealth or who can link to written explanations that are specific to Massachusetts laws rather than educated best guesses. I can make guesses too! But I want data and facts here.
Specific scenarios I have heard about and would like to verify/understand in greater detail:
1) Someone has MassHealth (which provides some dental coverage) as well as an additional plan that covers dental. Goes to a dentist who is in-network with both MassHealth and the other plan. Is told by the dental practice that they cannot become a patient there because of the MassHealth. (I believe this practice is no longer taking *new* MassHealth patients, which seems common. However this person did have other separate insurance that the practice takes.)
2) A primary care practice takes one specific MassHealth plan but does not take any others. They are (supposedly) per some law unable to see a patient that has a different MassHealth plan (for which the office is not in-network) even if that patient wanted to and agreed to pay out of pocket.
I suspect, but am not sure, that this might have something to do with laws about balance billing MassHealth patients--either in reality or in someone's misunderstanding of them at some point. What I would like to understand (in addition to whether these scenarios have been described to me accurately) how this plays out in more scenarios:
If the person in example 1 went to a dentist who does NOT take MassHealth but does take their second insurance, would this same thing have happened?
And more similarly to example 2, can MassHealth patients pay out of pocket to see specialists who take MassHealth but don't take their specific MassHealth plan?
What about therapists?
What about paying out of pocket to see a therapist who is officially in-network for MassHealth but is no longer accepting new clients except for self-pay clients? Can that therapist take cash from people who have MassHealth? If they officially cannot, is it something that just happens anyway, ie patient doesn't disclose that they have any insurance at all and just pays out of pocket from the get-go?
I would really really like to stress that I'm only interested in hearing from people who have specific experience with MassHealth or who can link to written explanations that are specific to Massachusetts laws rather than educated best guesses. I can make guesses too! But I want data and facts here.
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posted by needs more cowbell at 9:28 AM on June 13, 2022