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Commonwealth Care

State-subsidized health insurance is available to adult residents of Massachusetts (US citizens, nationals, and legal aliens) who are uninsured and meet income guidelines (up to 300% of the federal poverty level). DME is a covered benefit: co-pays and premiums vary by plan type.

Commonwealth Care is a state-subsidized program created by the Massachusetts 2006 Health Reform Law. It offers comprehensive free or low-cost health insurance to adult residents of Massachusetts (US citizens, nationals, and legal aliens) who are uninsured and meet income guidelines (up to 300% of the federal poverty level). Durable medical equipment is a covered benefit, and co-pays and premiums vary by plan type. MassHealth processes Commonwealth Care applications, but Commonwealth Care is designed and run by a new state agency, the Commonwealth Health Insurance Connector Authority.

Commonwealth Care has no asset tests, and requires no premiums from people who earn at or below 150% of the federal poverty level. For people who earn between 150.1% and 300% of the federal poverty level the lowest cost plans have adult monthly premiums that range from $0 to $116 per month (in 2011). However, not all plans are available in all regions, and some plan premiums are significantly higher.

Currently there are five Managed Care Organizations (MCOs) administering these plans (the same as administer MassHealth), and there are three types of Commonwealth Care plans. To learn more about plan types and costs visit the Health Connector website.

Who is Eligible?

If you are over age 19, a US citizen or legal resident, and earn less than 300% of the federal poverty level, you may qualify for a Commonwealth Care plan.

If you are over-income or otherwise ineligible for Commonwealth Care, see Commonwealth Choice. This program recommends commercial health insurance products that the Connector considers a good value for consumers.

What DME Services are Provided?

All four types of Commonwealth Care plans provide access to:

  • Durable medical equipment
  • Supplies
  • Prosthetics
  • Oxygen and respiratory equipment
  • Orthotics (for people with diabetes only)
  • Podiatry
  • Vision care (eye exams and eye glasses every 24 months)

DME costs vary by plan type:

Plan Type 1 charges no co-pays for these DME services. This plan type is for people whose income is at or under 100% of the federal poverty level.

Plan Type 2 charges no DME co-pay, but requires $10 for eye exam visits, $5 for podiatry visits, and $10 for visits to a specialist. Maximum out-of-pocket expenses per year are $750 for services excluding prescription drugs (which has a separate $500/year maximum out-of-pocket limit). This plan type is for people between 100.1% and 200% of the federal poverty level.

Plan Type 3 charges 10% of the cost of the DME ("coinsurance"), also $10 for podiatry visits, and $20 for eye exams. Maximum out-of-pocket expenses per year are $1500 for services excluding prescription drugs (which has a separate $800/year maximum out-of-pocket limit). This plan type is a choice for people between 200.1% and 300% of the federal poverty level.

How are DME Services Provided?

Commonwealth Care plans are provided through Managed Care Organizations, the same MCOs that serve many MassHealth members. These are BMC HealthNet, Fallon, Neighborhood Health Plan, Network Health, and Health New England. Like MassHealth, they also require "prior approval" for DME. Your plan's policy booklet will outline their process for obtaining DME. Review this carefully and call a member services representative with any questions. Below is an outline of how DME is generally acquired.

  1. Get a prescription from your doctor's office for the DME you need. The prescription may come from your primary care provider or a specialist. Depending on the equipment and the requirements of your MCO, you may also need a letter of medical necessity explaining how the equipment is part of your treatment for your medical condition.
  2. Take the prescription and letter of medical necessity (if necessary) to your MCO's preferred medical equipment supplier. Your primary care provider will likely know what supplier to refer you to (for example, Fallon uses Lakeview Medical). If the supplier does not carry the equipment you need, they should refer you to a supplier who does.
  3. If necessary, the supplier will evaluate you to see exactly what equipment you need. In these cases, your doctor may refer you to the supplier before providing a prescription. After evaluating your needs, the supplier then contacts your doctor's office to get the appropriate prescription.
  4. The supplier will file the request for "prior approval" directly with your MCO. Preferred providers report, however, that not everything requires prior approval, particularly if the item is in stock. Some prescriptions may be filled immediately.
  5. If prior approval is necessary, the MCO should be able to respond to the request within a few days (according to medical equipment suppliers). Urgent requests can be the same day.
  6. If prior approval is denied, your MCO will send you and your ordering physician (whoever wrote the prescription) a denial letter. More information from your doctor may be necessary to approve the request. The MCO's denial letter must list your appeal rights.

What If I Need to Appeal a Denial for DME?

Denials are common so it may be best to consider them just another step in the process of obtaining DME. Often providers just need more information and supporting documentation to approve a claim.

If your insurance provider denies your request, you should file an appeal as soon as you can. (Federal law, however, gives you up to 180 days to appeal a decision from the service date.) The appeals process is the same for Commonwealth Care plans as it is for any commercial (private) health plan (MassHealth regulations do not apply to Commonwealth Care even though MassHealth is in charge of Commonwealth Care enrollment). Your denial letter (sometimes an "explanation of benefits") must detail your appeal rights and procedures. Review and follow these carefully. It's a good idea to keep all correspondence, forms you fill out, and even a written record (log) of whoever you speak with and the actions you take.

The first step is to follow your MCO's "internal review" procedures; this is the health plan's own grievance process. Each MCO (and private HMO) has a formal internal appeals process governed by Office of Patient Protection (OPP) regulations (105.CMR.128). If you feel you are denied unfairly by this internal review, you can next ask for an "external review." This is an independent appeals process conducted by the Office of Patient Protection (part of the Massachusetts Department of Public Health). OPP external review decisions are final.

The Kaiser Family Foundation provides a useful guide for how to pursue internal reviews as well as external reviews of your private (or Commonwealth) health insurance claim denial. The guide also helps explain health insurance coverage and relevant state and federal laws: see this Kaiser Family Foundation web page.

Frequently asked questions about the external review process are also available at this Office of Patient Protection web page (click on "External Review Process" in the Quick Links and then choose the "External Review Overview").


Commonwealth Care Customer Service Center:
(877) 623-6765 VOICE
(877) 623-7773 TTY
Health Connector website

Health Care For All's Health Helpline: (800) 272-4232
(This is a non-governmental organization that answers questions about healthcare in Massachusetts)