Frequently Asked Questions
An ombudsman is someone who acts as a mediator or go-between when people need help resolving a dispute. Many types of organizations, from government offices to universities, offer ombudsman services to investigate issues raised by their members. There are many kinds of ombudsmen, but what they have in common is their role investigating all sides of a conflict to help everyone involved find common ground.
My Ombudsman helps MassHealth members who need help accessing their covered benefits and services. We are mediators and help keep the lines of communication open between members, MassHealth, providers, or other parties. We offer support, and we respect everyone's unique story, boundaries, and goals.
We help MassHealth members with all kinds of issues. Some reasons people contact us include: wanting help filing an appeal or grievance; problems getting approval for Personal Care Attendant (PCA) or other home and community-based services; disputes about a medical bill; or difficulty accessing their MassHealth benefits, like non-emergency medical transportation or medical supplies.
These are just some of the issues we can help with. If you aren’t sure whether we can work with you, you are always welcome to reach out and ask.
We serve anyone enrolled in MassHealth, including:
Members who get their MassHealth Limited via Fee for Service (FFS), such as members who have both Medicare and MassHealth
Members who have MassHealth Limited or Children’s Medical Security Plan
Members enrolled in:
Accountable Care Organizations (ACOs)
Managed Care Organizations (MCOs)
Primary Care Clinician (PCC) plan
Massachusetts Behavioral Health Partnership (MBHP)
One Care
Senior Care Options (SCO)
Program of All-inclusive Care for the Elderly (PACE)
We can work with members of any of these types of MassHealth health plans. If you’re a MassHealth member, but you don’t know what kind of MassHealth you have, we’re happy to help you find out.
My Ombudsman can work with you one-on-one to discuss your rights and choices if you disagree with a coverage decision your health plan made. In general, you have the right to file an appeal or a grievance.
An appeal is an official way of asking your health plan (or in some cases MassHealth) to change a decision. When you file an appeal, you get to tell your health plan or MassHealth in your own words why you disagree with their decision. The provider who requested the service or care that was denied can also help with this process.
A grievance is a formal way of telling your health plan that you are not happy with their actions. This type of complaint is a way to get your concerns “on the record,” but it may not result in a different outcome or change their decision. The plan is still required to respond (usually in writing) to your concerns.
My Ombudsman can help you understand why your service was denied, explore your choices, and help you navigate the process of an appeal or grievance. We can’t represent you in an appeal, which means we can’t serve as your advocate and tell MassHealth or your health plan to make a decision in your favor.
There are many reasons why a member can receive a denial letter. For example: Maybe MassHealth or your health plan needs more information. Or maybe the service requested is not something MassHealth or your health plan usually covers. Maybe the health plan and doctor disagree about whether the service is medically necessary. Or, the reason may be something else altogether.
If you receive a letter like this, we suggest reading it carefully and holding onto it. The letter should describe the reason for your denial and the next steps you can take, like filing an appeal. Contact your MassHealth or your health plan if you need help understanding what the letter says. If you need further assistance, you are welcome to contact My Ombudsman. We can discuss the letter together to see if we can help you understand the health plan’s decision. We can also discuss your options, including your right to ask for an appeal.
If you’ve tried contacting your doctor, your pharmacy/supplier, and your health plan without success, call My Ombudsman and we will try to help determine why you are unable to get the refill. If it is an insurance-related issue, we will work with your plan and your care team to try to find a solution. Our hours are 9am-4pm, Monday-Friday. We are closed on major holidays.
NOTE: If you are experiencing a life-threatening emergency, please call 911 or go to your local emergency room.
No, My Ombudsman works exclusively with MassHealth members. Please contact the plan’s member services department. The phone number is usually printed on your member ID card or can be found on the health plan’s website.
No, My Ombudsman works exclusively with MassHealth members.
The Health Connector Consumer Ombudsman can help resolve problems related to Health Connector billing, enrollment, website function, or customer service. For any other issue, contact your insurance plan’s member services department. The phone number is usually printed on your member ID card or can be found online.
Yes. We can work with anyone who is a current member of MassHealth, whether they have a disability or not. We support DPC’s mission to advance disability rights by protecting everyone’s access to healthcare. Our staff includes people from diverse professional, educational, cultural, linguistic, and personal backgrounds because the people who contact us come from all walks of life.
If your question or concern is related to a MassHealth benefit, we can help. If you do not, we will still do our best to refer you to the right place. One common place we refer to is SHINE (Serving the Health Insurance Needs of Everyone) They provide free health insurance information and counseling to all MA residents with Medicare. You can call SHINE at (800) 243-4636.
My Ombudsman is not a part of MassHealth or any health plan. When you contact My Ombudsman, the person you talk to is not a MassHealth employee. We are an independent program run by a non-profit organization.
The MassHealth Customer Service Center can help all MassHealth members, with a wide range of questions and concerns. For example, they can provide information about your eligibility for MassHealth coverage and help you enroll in a MassHealth health plan. They can help you apply for MassHealth, give information about your health plan benefits, or help you replace a lost MassHealth member ID card. You can call the MassHealth Customer Service Center at (800) 841-2900.
My Ombudsman works with people who are already enrolled in MassHealth (members.) Our job is to help members with all kinds of questions and concerns about accessing their health plan’s covered benefits and services. We offer “hands-on” support while we work with you to investigate and resolve your problem.
Yes, if you are a SCO member or a One Care member, we can help you. We can work with you and your care team to find a solution to your issue.
Our staff cannot act as personal representatives and we do not give any legal advice. We can provide contact information for legal advocacy organizations, usually ones who work at no or low cost. We can also discuss your right to have a non-legal representative at an appeal hearing.
No, a Long-Term Care Ombudsman is an advocate working to resolve problems related to the health, welfare, and rights of individuals living in nursing or rest homes. These Ombudsmen visit facilities on a regular basis and offer a way for residents to voice their complaints and work towards a resolution with staff.
My Ombudsman serves MassHealth members when they have a question or problem with their health plan benefits or services, whether they are living in a long-term care facility or not.
You can call (800) 243-4636 to connect with your local long-term care ombudsman. Or you can find the contact information for your local long-term care ombudsman by clicking here.
Sometimes people discover that their MassHealth coverage has ended or changed, and they don’t know why. As a result, they can’t access important services like prescriptions, mental health care, or treatment for chronic conditions. If you are in this kind of situation, we suggest calling the MassHealth Customer Service Center at (800)-841-2900 or the Health Care for All helpline at (800)-272-4232. You can also call My Ombudsman and we will explore options for getting access to any medically necessary services as soon as possible.
Yes. MassHealth covers medically necessary COVID-19 treatment ordered by a health care provider, for all members, no matter what kind of MassHealth coverage or plan they have. Getting tested or treated for COVID-19 when it is medically necessary is free and will NOT impact your immigration status. Learn more about what is covered from the Masshealth website: https://www.mass.gov/info-details/masshealth-coronavirus-disease-2019-covid-19-applicants-and-members#masshealth-coverage-for-testing-and-treatment-of-covid-19-
Not every COVID-19 testing site accepts MassHealth, and different testing sites accept different MassHealth health plans. Check with your healthcare provider, insurance plan, care manager, or MassHealth’s COVID-19 information website for applicants and members to find a covered or free testing site near you.
All One Care members have access to a Care Partner, Care Manager, or Care Coordinator and a care team. Your Care Partner, Care Manager, or Care Coordinator’s job is to make sure everyone on your care team is working together to help you get what you need. One Care members also have the right to add a Long-Term Supports (LTS) Coordinator to their care team for additional support. If you have needs you feel are not being addressed, start by talking with your Care Partner, Care Manager, or Care Coordinator, your providers, and/or other members of your care time, like your LTS Coordinator. If you’ve already talked to your care team and you need more help, you can contact My Ombudsman.
One Care members can attend monthly meetings held by the One Care Implementation Council (IC). This committee plays an important role in promoting accountability and transparency within One Care. Click here to learn more. All One Care plans also have a consumer advisory Council (CAC) that members can join, and plans may have other ways members can provide feedback. Contact your plan to find out how you can get involved.
Yes. Your One Care plan covers all the same DME as MassHealth and Medicare, and may cover additional DME. Everyone’s needs are different, so work with your care team - your healthcare providers and your Care Partner, Care Manager, or Care Coordinator to find out if your DME will be covered. Your care team can also help coordinate fittings, repairs, and more. There is no out-of-pocket cost for DME.
One Care members never have to pay any co-pays or fees to get care, but sometimes providers may send bills by mistake. In rare circumstances, a member may get a bill if One Care doesn’t cover the service they received, if Medicare was billed rather than your plan, or if the care required approval before getting it. You might also get a bill if the care was from an out-of-network provider (though there may be exceptions to this). If you receive a bill, contact your One Care plan right away to find out why and what you can do.
To help avoid these situations, it is a good idea to check with your plan before you get a service to make sure it will be covered. If you need help with a billing issue, contact your One Care plan or feel free to reach out to My Ombudsman for guidance.
There are no (co-pays) for prescriptions if you join One Care. Learn more about One Care’s prescription coverage here.
Each One Care plan has their own list of covered medications (click here to learn more ) that includes all drugs covered by MassHealth and Medicare Part D and may also include over-the-counter medications like vitamins, allergy pills, and nicotine patches (with a prescription). To know whether your One Care plan covers a specific medication you need, you can look at your plan’s list or call your plan.
One Care offers many services to help members live independently at home and in the community. These are called long-term services and supports, or LTSS. LTSS includes things like healthcare you get at home, medical equipment (like wheelchairs, hospital beds, or oxygen), day programs, and more. One Care members have the right to add a Long-Term Supports (LTS) Coordinator to their care team to help them understand the options and arrange for LTSS. LTS Coordinators work for organizations in the community. They are independent form the One Care plan). Click here to learn more.
If you think you may need PCA services, let your PCP or care team know that you would like an assessment for Personal Assistance Services (PAS) to see if your needs meet the criteria for a PCA. You will also be asked about any needs for Long Term Services and Supports (LTSS), including any need for personal assistance services, during your comprehensive assessment. In general, to qualify for PCA services, you need to have a chronic or permanent disability that stops you from doing your own personal care, and you have to need (hands-on) help with 2 to 7 Activities of Daily Living (ADLs). This includes bathing, dressing, taking medications, cooking, eating, toileting, and laundry. If you need cueing and monitoring to complete some ADLs, you may be able to get PCA services as well. PCA support with cueing and monitoring is only available through One Care. Your care team and Long-Term Supports (LTS) Coordinator (if you choose to get one) will help guide you through the process of getting a PAS evaluation and PCA services as you may need.
If you do not qualify for PCA services, your care team can help you think through other support services that may be available to meet your needs. All One Care members also have the option to have a Long-Term Supports (LTS) Coordinator who may be able to give more education and support around your options. If you need more help understanding PCA services, contact My Ombudsman.
Yes. One Care offers both medical and non-medical rides through a variety of companies. You can get rides to medical appointments and to places like the grocery store or the pharmacy. There are some limits on what kinds of non-medical rides are available and how many non-medical rides you can get each month. To learn more about what transportation services are covered and how to request rides, you can call your One Care plan or ask your Care Partner, Care Manager, or Care Coordinator.
One Care members can get all the dental services MassHealth covers. (check here for a list). To receive services, you will need to go to a dental provider in your One Care plan’s network. Your One Care plan may also need to approve the service ahead of time (meaning they require prior authorization). Contact your Care Partner, Care Manager, or Care Coordinator for more information about dental benefits and how to find a provider. Or, reach out to us at My Ombudsman if you need more help.
In the first 90 days after you join One Care, you will get a comprehensive assessment so that you and your care team can talk about your needs. After the assessment, you will work with your Care Team to make your individualized care plan (ICP). Every year, your Care Team will work with you to update your ICP in case there is a change in the health services you need and want. Your ICP can also be updated as your goals or needs change throughout the year.
An ICP identifies the health-related goals that you want to address, such as getting services for your physical and mental health care and getting long-term services and supports. They can also help coordinate: the providers you see, the medications you take, and can help you with any health-related social needs like getting housing and food supports. You will be able to record your health, independent living, and recovery goals. You will be at the center of this process to create your ICP.
Your Care Team will work with you to update your ICP any time your needs change or you want to add new needs or goals. Your Care Partner, Care Manager, or Care Coordinator will review and update your ICP with you at least once every year. Reach out to them if your goals or needs have changed, or if you have any questions about your ICP. Feel free to contact My Ombudsman if you need more help.
When you join One Care, your One Care plan will tell you who your Care Partner, Care Manager, or Care Coordinator is. This person is a key member of your care team, so it’s important to know who they are and how to reach them. If you don’t know their name (or forgot it), you can call your One Care plan to ask who they are and how to contact them. Feel free to contact My Ombudsman if you need more help.
Care coordination means that all behavioral health, medical, and community service providers work closely with each other, your primary care provider (PCP) and with you to help you get the care you need.
Care coordination includes:
Managing your care with your provider and other health care and social services agencies working to improve your health.
Helping you with transitions between different care settings such as from the hospital back to home or to a nursing facility
Every One Care member gets a care coordinator (that may be called a Care Coordinator, Care Partner or Care Manager depending on your plan,) to help coordinate your care, and a member’s care is provided through a care team. One Care’s approach to care coordination puts the member at the center of their own care team. The care team also includes someone who may be called your Care Coordinator, Care Partner or Care Manager; providers; and other supports you may want. In One Care, the care team helps with coordinating services according to your individualized care plan.
If you want, you can also choose to have a Long-term Supports (LTS) coordinator to help you find resources and benefits available to you in your community.