One Care: MassHealth Plus Medicare Progress Report and Implementation Issues SNP Leadership Forum October 10, 2013 Presented by Robin Callahan, Deputy Medicaid Director

Presentation Overview of One Care Target population Delivery system and care model Enrollment process Development timeline and stakeholder engagement Integration successes and challenges in MOU and three-way Contract Financing Administration Oversight and quality measures Status update and implementation focus areas for 2014 2 2 2 2 2

One Care Target Population Target population is 111,000 dual eligibles ages 21-64 with full MassHealth and Medicare benefits To be eligible to enroll, a person must be: Age 21 to 64 at the time of enrollment; Eligible for MassHealth Standard or CommonHealth; Enrolled in Medicare Parts A & B and eligible for Medicare Part D; Without other comprehensive insurance; Not enrolled in a Home and Community-based Services (HCBS) waiver; and Not residing in an Intermediate Care Facility (ICF/MR) 3

Target Population Snapshot (CY 2010 Data) Over two-thirds of the target population has a behavioral health diagnosis Approximately 50% have a chronic medical diagnosis 8% have an intellectual or developmental disability Approximately 25% use LTSS 96% in the community, not a long-term facility 4 4

Covered Services Medicare Services: All Part A, Part B, and Part D services Medicaid State Plan Services* Additional Behavioral Health Diversionary Services, e.g.: Community crisis stabilization, Community Support Program, acute treatment and clinical support services for substance abuse, psychiatric day treatment Additional Community Support Services, e.g.: Day services, home care, respite care, peer support, care transitions assistance (across settings), Community Health Workers Additional services are meant as alternatives to advance wellness, recovery, self-management of chronic conditions, independent living, and as a means to avoid high cost acute and long-term institutional services 5 5 *Excluding certain services provided by other state agencies: Targeted Case Management, Department of Mental Health Rehabilitation Option, and Intermediate Care Facility services 5

Delivery System and Care Model One Care plans, contracted jointly by MassHealth and Medicare, will provide for members: Integrated Medicare and MassHealth benefits Person-centered planning, with integration across medical, behavioral health and LTSS needs Personal care plan directed by the enrollee, informed by comprehensive in-person assessment of medical, behavioral, and functional needs Interdisciplinary care teams, with Care Coordinators and Long Term Supports (LTS) Coordinators (see next slide) Plans must perform comprehensive in-person assessment within 90 days of a member’s enrollment, to be the basis for the personal care plan Continuity of care: For the first 90 days, or until the plan completes the assessment, the plan must allow enrollees to maintain current providers at current rates and honor prior authorizations issued by MassHealth and Medicare 6

LTS Coordinator One Care plans are required to contract with community-based organizations to provide LTS Coordinators LTS Coordinator must have no financial interest in the determination of an enrollee’s type or amount of services LTS Coordinator will work with plans and enrollees to incorporate community-based services as appropriate into care plan LTS Coordinator is a member of the care team, at the enrollee’s discretion Will participate in assessments for individuals in a facilities or community-based LTSS users Must be made available at any time at an enrollee’s request Will be involved whenever admission to a facility is contemplated 7

One Care Plans and Service Areas Three One Care plans providing coverage on a county-by-county basis Commonwealth Care Alliance (8 full counties and 1 partial county) Fallon Total Care (3 counties) Network Health (2 counties) 14 counties in Massachusetts overall Approximately 90,000 individuals in target population will have access to at least one One Care plan 8

Enrollment Process Enrollment will occur via voluntary, opt-out process At any time, enrollees may opt-out or transfer between plans, on a month-to-month basis MassHealth began mailing enrollment packages and accepting requests to enroll in September Self-selection process For October 1 effective date Self selection will continue throughout the demonstration 9

Enrollment Process – Auto-Assignment In addition to ongoing self-selection, auto-assignment will occur for some individuals who do not indicate a choice of plan or to opt out Auto-assignment pool limited to individuals who received initial enrollment packet and live in a county with at least two plans Expect 3 rounds of auto-assignment, with effective dates of Jan. 1, 2014, April 1, 2014, and July 1, 2014 First round will include only those with relatively lower acuity MassHealth is working to match individuals to a One Care plan that has their primary care provider in its network Two notices (60-day and 30-day) will be mailed to individuals who have been auto-assigned, allowing time to change plans or opt out 10

Development Timeline MOU signed August 22, 2012 Plans selected for Readiness Review and contract negotiations November 2012 Readiness Review and contract development began December 2012 Three-way contracts signed July 16, 2013 Final Readiness determinations made August 2013 Enrollment mailings and plan marketing began September 2013 First coverage effective date is October 1, 2013 11 11 11 11 11 11

Stakeholder Engagement MassHealth has had robust stakeholder engagement throughout the project 36 open stakeholder meetings and workgroups on quality, member notices, and assessment since 2010 Focus groups Consumer involvement in procurement to select One Care plans Consumer participation in developing outreach materials, notices, and trainings about One Care Implementation Council Developed at the request of stakeholders seeking a formal role for consumers in implementation 21-member body, majority consumers (and/or family members); providers or trade associations community orgs, unions also represented Members diverse in geography, disability, race/ethnicity, etc. 12 12

Integration Successes and Challenges 13 13 13

Financing - Integration through Global Payment Medicare Parts A/B Medicare Part D Medicaid LTSS, behavioral health, and medical services not covered by Medicare Inpatient and outpatient medical services Prescription drugs Risk-adjusted using HCCs Risk-adjusted using Rx HCCs Risk-adjusted using rating categories Risk-adjusted Medicare A/B payment + Risk-adjusted Medicare D payment + Medicaid Rating Category payment =TOTAL MONTHLY CAPITATION 14 14 14 14 14 14 14

Medicare Rate Adjustments Rates, Reassurances, Risks Preliminary Rate Structure Final Rate Structure Medicare Rate Adjustments Savings Target Sustainable Growth Rate Coding Intensity Adjustment Rural Floor Bad Debt 1% for first seven quarters of Demonstration1 < 6 months = 0% > 6 months – Dec. 2014 = 1% Year 2 = 1.5% Year 3 = >4%2 Rates adjusted to account for legislative action to protect provider payment levels3 Rates calculated and applied without coding intensity adjustment in CY 2013. CMS will apply coding intensity adjustment in CY 20142 2013 payments will be based on relationship of each county’s spending to national spending for 2006-20104 Rates adjusted to account for higher payment rates to Massachusetts hospitals3 Rates adjusted to reflect share of bad debt attributable to population3 1: Duals Demo: Issue and Response document 12/12 2: MA 3-way Contract 3: MassHealth Presentation 5-17-13 4: MA Duals RFR Responses to Bidders Question 8/12

MassHealth & Medicare A/B MassHealth Rate Adjustments Rates, Reassurances, Risks Preliminary Rate Structure Final Rate Structure MassHealth & Medicare A/B Risk Corridors Gains/losses1 up to 5% =no risk sharing 5-10% = 50% sharing w/ CMS & MassHealth > 10% = no sharing Gains/losses2 0-1% = no risk sharing 1.1-3% = 90% shared by CMS & MassHealth, 10% by plans 3.1-20% = 50% sharing w/CMS & MassHealth > 20-100% = no sharing MassHealth Rate Adjustments Rating Categories (RC) High Cost Risk Pools (HCRP) C3 & C2 refined and split into 2 categories to capture higher cost enrollees based on certain diagnosis. C2A & C2B C3A & C3B Auto assignment delayed for C3 and C2 (Community High Behavioral Health) until CY 20142 F1 – Facility-based Care C3 –High Community Needs C2 –Community High Behavioral Health C1 –Community Other3 A portion of the payment for RC C3 (High Community Need) and F1 (Facility-based Care) withheld to create Pool –the HCRP will be distributed based on applicable spending over per-enrollee threshold and the excess pool will be distributed back to plans in proportion to their contributions1,2 1: MOU between CMS and EOHHS 2: MA 3-way Contract 3: MA Duals Demonstration RFR

Administrative Integration Reconciling and integrating different MassHealth and CMS systems and processes proved challenging Some successes around enrollment, with MassHealth as the single enrollment broker, but challenges adapting CMS’s enrollment policies and notices to align with MassHealth operations Achieved integrated appeals notices, though process beyond plan-level appeals remains bifurcated Did not fully reconcile or collapse coverage differences for “overlap” services (e.g. DME, home health) For providers – MassHealth is offering training in topics that are non-plan specific Plans are collaborating in some areas, e.g. ADA compliance

Oversight and Quality Integration Will work closely with CMS to oversee One Care plans through joint Contract Management Team structure For plans, some administrative and quality reporting requirements remain somewhat separate between MassHealth and CMS HEDIS, HOS, and CAHPS measures consistent with Medicare requirements All existing Part D metrics Additional MassHealth-proposed metrics pertinent to target population, in such areas as: Care management, appropriate care, follow-up for behavioral health Person-centered care planning, management, transitions Access to care, including LTSS services and ADA compliance

Status Update and Implementation Focus Areas 19 19 19

Status Update Coverage effective Oct. 1 for those who enrolled in September Auto-assignment process underway in preparation for sending 60-day notices Actively interfacing with plans and CMS on a near-daily basis for troubleshooting Ongoing regular meetings with all plans on key implementation topics Continuing monthly meetings with stakeholders

Key Implementation Focus Areas for 2014 “Early indicators” metrics: to track customer service, enrollment systems, plans’ process for receiving new enrollees, and members’ early perceptions and experiences of One Care Transition from continuity of care period to services covered by plans, especially inclusion of LTSS in care plans Cultural competence and accessibility of plan staff and providers Opportunities to streamline processes and requirements where feasible, both for plans and providers (e.g. reporting requirements, appeals, training

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