MassHealth Restructuring Update Jeff Keilson June 7, 2016

MassHealth Restructuring The problem Unsustainable growth, almost 40% ($15B+) of state budget Current fee-for-service model results in fragmented, siloed care Major Goals  Stop the growth of MassHealth spending  Improve quality and access  Reduce avoidable ED usage and hospital admissions Target Population MassHealth “only” members Excludes those with MassHealth and Medicare or commercial lnsurance All ages Organized in 5 MassHealth Regions 4 Components ACOs Community Partners/Health Homes MCOs to support ACOs DSRIP (Delivery System Reform Incentive Payment Program) funding (infrastructure/transformation) 2

MassHealth Restructuring: ACOs ACO role ACOs are provider-led organizations that coordinate care, have an enhanced role for primary care, and are rewarded for value- improving total cost of care and outcomes- not volume Provider led= group of providers or a health system ACO goals and principles Improve member experience Strengthen member/PCP relationships Develop high value, clinically integrated provider partnerships via coordinated care teams, preferred networks Partner with MCOs to help administer ACO Increase BH/LTSS integration and linkages to social services Functions Total cost of care responsibility Overall Utilization Management Preferred provider network development Coordinated care team development with providers across continuum PCP sign off on care plan/service authorizations Ongoing evaluation, quality, and care team performance improvement Enrollment Members choose an ACO based on PCP selection Reimbursement methodology ACO payments linked to performance on quality metrics on multiple domains 3

MassHealth Restructuring: Health Homes Certified BH Community Partner Population: SMI, SED, SUD Functions Health Home services BH services Linkages to social services Certified LTSS Community Partner Populations: various populations who utilize LTSS services- elders, adults and youth with physical disabilities, acquired or traumatic brain injury, I/DD, co-occurring BH&LTSS needs Functions LTSS care coordination Clinical and functional assessments Advise members on options Linkages to social services Flexible services ACOs funded to address social determinants of health by reimbursing for none- traditional services and supports to improve health outcomes Health Home Services Care Management Care Coordination Health Promotion Transitional Care Individual and Family Support Referrals to Social and Community Support Multiple per region Eligible providers BH Community Partner Community-based providers OP BH provider For youth: CSA or have agreement with CSA LTSS Community Partner Community-based providers Expertise in serving multiple populations of people with disabilities 4

Additional Components Managed Care Organizations (MCO) In some of the ACO models, MCOs partner with ACOs to help them administer the ACO MCO remains the insurer, pays claims Work with ACOs to improve care delivery and support integration of care Assist with provider network development and management Support providers to build provider capacity, including providing data analytics for population health management Support provider-based care management DSRIP Funding Delivery System Reform Investment Program via CMS Statewide investment to support system transformation and infrastructure development Support ACOs, develop BH/LTSS community capacity, address health-related social needs State proposing $1.5B+ upfront investment 5

MassHealth Restructuring: Timeline 6 ComponentMilestoneTimeline ACO pilot-applications open -selection -launch May 2016 September 2016 December 2016 Full ACO roll-out-applications open -selection -DSRIP funding starts -launch July/August 2016 December 2016 July 2017 October 2017 MCO procurement -applications open -responses due -selection -launch October 2016 Jan/Feb 2017 May 2017 October 2017 Community Partner/ Health Home -applications open -responses due -Certification -DSRIP funding starts, launch September 2016 December 2016 February 2017 July 2017 DSRIP statewide investments -phased application, selection -funding starts, launch Sep 2016-Mar 2017 July onward