ACAP Dual Eligibles Toolkit: Summary Data for Massachusetts Compiled by: Special Needs Consulting Services (SNCS)

Key Information, Massachusetts Massachusetts has roughly 240,000 “full duals” 52% of these persons are age 65+ The full duals’ annual costs (across Medicaid and Medicare) now total approximately $300 billion – roughly $50,000 per person per year 65% of these expenditures are paid for by Medicaid SNCS estimates that 10% of the Massachusetts duals’ costs are currently paid via capitation; 90% via FFS Massachusetts submitted a Memorandum of Understanding to CMS authorizing the Massachusetts Duals Demonstration in August 2012 MCOs interested in serving duals under this demonstration need to engage in significant preparations during CY2012 (and CY2013) Average lifetime revenue for each dual eligible enrolled is likely to exceed $500,000, since most duals will remain eligible and enrolled for remainder of their lives (which should average > 10 years) The high needs and high costs, coupled with the “rest of life” enrollment dynamic, creates profound and exciting care coordination opportunities Moving Massachusetts’ duals into coordinated care also makes market positioning critically important right now for MCOs interested in serving this subgroup

Estimated PMPM Cost, Massachusetts Full Duals, 2008 Age <65 Age 65+ All Full Duals Average Eligibles 109,276 111,485 220,761 Total Medicaid Cost $1,077 $1,668 $1,375 Nursing Home $151 $1,065 $612 Capitated Care $22 $180 $102 HCBS Waiver & Prosthetics $207 $149 $178 Personal Support $119 $80 $99 ICF/MR $101 $42 $71 All Other Medicaid $477 $152 $313 Estimated Medicare Costs $1,124 $1,340 $1,233 Part A $386 $614 $501 Part B $388 $492 $441 Part D $350 $233 $291 Total Costs, Medicaid & Medicare $2,201 $3,008 $2,609

Estimated Total Dollar Cost, Massachusetts Full Duals, 2008 Age <65 Age 65+ All Full Duals Average Eligibles 109,276 111,485 220,761 Total Medicaid Cost $1,412,351,919 $2,231,194,632 $3,643,546,551 Nursing Home $197,495,810 $1,424,286,699 $1,621,782,509 Capitated Care $28,933,176 $241,211,266 $270,144,442 HCBS Waiver & Prosthetics $271,939,697 $198,694,987 $470,634,684 Personal Support $155,915,691 $107,264,855 $263,180,546 ICF/MR $132,467,919 $56,362,195 $188,830,114 All Other Medicaid $625,599,626 $203,374,630 $828,974,256 Estimated Medicare Costs $1,474,501,764 $1,792,389,134 $3,266,890,898 Part A $506,418,298 $822,013,979 $1,328,432,277 Part B $508,682,523 $658,533,915 $1,167,216,438 Part D $459,400,942 $311,841,241 $771,242,183 Total Costs, Medicaid & Medicare $2,886,853,683 $4,023,583,766 $6,910,437,449

Publicly Available Resources Containing Data and/or Other Information About Massachusetts’ Dual Eligibles Medicare-Medicaid Enrollee State Profile, Massachusetts, Centers for Medicare & Medicaid Services http://www.integratedcareresourcecenter.com/PDFs/StateProfileMA.pdf Massachusetts State Demonstration to Integrate Care for Dual Eligible Individuals https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/Downloads/StateSummaryMA.pdf Dual Eligibles in Massachusetts: A Profile of Health Care Services and Spending, September 2011, Massachusetts Medicaid Policy Institute & MassHealth http://bluecrossmafoundation.org/~/media/MMPI/Files/MMPI%20Duals%20Chart%20Pack.pdf Achieving Optimal Care Coordination for Medicaid/Medicare Dual Eligibles, August 2011, Special Needs Consulting Services (Joel Menges, Jeremy Batt, Kaleigh Beronja, Jessica Wiecezak) http://www.sncservices.com/Achieving%20Optimal%20Care%20Coordination%20for%20Dual%20Eligibles-%20FINAL.pdf