The Massachusetts Consumer Assistance Program (MA-CAP)
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What is MA-CAP?
On March 23, 2010, President Obama signed the Patient Protection and Affordable Care Act (PPACA) into law. Under this new law, consumers have new rights and resources with respect to their health insurance. Federal grants were distributed to states to create Consumer Assistance Programs (CAPs) to help consumers enforce these new rights. In Massachusetts, the Commonwealth’s Executive Office of Health and Human Services and two non-profit organizations, Health Care for All (HCFA) and Health Law Advocates (HLA) have partnered to carry out the following functions of the MA-CAP:
Help consumers file complaints and appeal against a health plan
Help consumers enroll in a health plan
Help consumers understand and navigate their health coverage and benefits
Enrollment in Health Insurance
If you are uninsured and need help enrolling in health insurance, contact the HelpLine at Health Care For All:1-800-272-4232.
Right to Appeal Health Care Decisions
Indviduals have the right to appeal or ask their insurance plans to reconsider their decision if they reject payment claims, services, or treatments. If the insurance company does not accept the appeal, consumers can request an external independent review of the insurance company's decision.
How do I Appeal a Decision by My Health Plan?
If you need help filing a complaint or appealing a decision by your health plan, please call 888-211-6168 or see HLA’s Fact Sheet. All services are FREE.
What is the External Review Process?
If you have gone through the internal appeals process with your health plan and your health plan upheld its decision to deny payment, services, or treatment, you may have an opportunity to file an external review with an independent review organization, like the Office of Patient Protection.
How do I File an External Review of My Health Plan’s Decision?
The Office of Patient Protection (OPP) in the Department of Public Health administers an external review process for those enrolled in fully-insured health plans subject to Massachusetts law. The OPP performs an independent medical review of your case. Please note that this process does not apply to MassHealth/Medicaid, Medicare, federal employee plans or self-funded, employer sponsored plans. If you are eligible for an external review through OPP, your health plan will give you the OPP external review request form with the letter of denial. If you have questions about the form or the Massachusetts external review process you may call OPP at 1-800-436-7757 or review the “Frequently Asked Questions” on the OPP website at www.mass.gov/dph/opp.
What if My Plan is a Self-Insured, Employer-Sponsored Plan?
Self-insured, employer-sponsored health plans are not subject to external review by the Office of Patient Protection. Instead, a federal external review process applies to non-grandfathered, self-insured plans. You will need to talk with your health plan about how you can initiate an external review of the denied payment or coverage. For consumers of health plans falling within this category, you should have at least four months from the internal appeal denial to file a request for external review with your health plan. You should provide any additional information that may support your claim to the independent review organization that has contracted with your self-insured health plan.
Glossary of Terms
While MA-CAP is ready to assist consumers with questions regarding health insurance coverage, you can find a glossary of health insurance terms that may help answer your questions here.