sco Senior Care Options Bringing Medicare and MassHealth Together

Problem: Current Health Care System Structural/payment bias towards institutional care No incentives to preserve health & independence No flexibility to meet individualized needs Difficult “navigation” during medical crises and transitions Multiple, conflicting Medicare & Medicaid rules No accountability for performance & outcomes

PACE: Important First Step Enriched day care model initiated by OnLok, San Francisco Nursing home certifiable enrollee able to live in community with supports Extensive interdisciplinary team Six providers in Mass – 13 PACE centers – over 1600 enrollees Quality care demonstrated, especially in preventable hospitalizations & chronic care management

Moving to Senior Care Options (SCO) Incorporate lessons learned from PACE CMS partnership Managed care model Medicaid financial eligibility interface Expand populations served Apply multiple rating category payment system Integrate geriatric expertise from aging agencies Streamline interdisciplinary team Allow enrollees to keep/choose own MD Offer statewide availability

SCO Objectives Align Medicare and Medicaid program and financing incentives via CMS-state partnership Establish accountability for delivery, coordination, and management of quality health care to high-risk dual eligible seniors Maintain seniors longer in their homes and communities by integrating all aspects of acute, preventive and long term care Achieve cost savings over time through prevention of disability and deterioration

SCO Milestones 2000: CMS-state demonstration MOU 2001: Medicare rate development 2002: State legislation 2003: Joint procurement- SCO selection 2004: Readiness, 3-way contracting, Enrollments begin 2005: MMA – MA-PD applications 2006: Special Needs Plan (SNP) status

SCO Highlights Voluntary participation, with individualized plan of care signed by each enrollee Centralized Enrollee Record (CER) 24/7 access to Nurse Case Manager (NCM) SCO accountability to CMS and state for meeting geriatric standards of care “Extra” benefits, not routinely available in fee-for-service, to encourage enrollments Multiple Medicaid rating categories supporting transitions across clinical levels/settings of care

SCO Payment Model Separate Medicare & Medicaid monthly capitation rates combined at SCO contractor level Medicare rates: individual diagnosis-based rates (HCC) per Medicare Advantage Medicaid rates: 24 rating categories supporting all levels of care in community & nursing facility (NF) settings Medicaid NF 3-month transition incentives to encourage community care

SCO Enrollee Benefits Choice of Primary Care Physician/Team Access for enrollees and caregivers to NCM 24/7 CER - transitions: home-hospital-nursing facility Full scope of flexible health care services Part D covered – with no co-pays or deductibles Relief from Medicare & Medicaid screenings and paperwork Access to full range of community supports through geriatric services social worker (AAA)

Benefits to SCO Network Providers Nurse & SW support to PCP in Primary Care Teams (PCTs) CER & nurse care management available 24/7 Geriatric, behavioral health, other clinical specialty consults as needed Creative, flexible services for enrollees – whatever PCP/PCT determines Opportunity for non-traditional contracting beyond fee-for-service limitations

Who Are the SCOs? Evercare: Subsidiary of United Health Care -service area essentially statewide Commonwealth Care Alliance: 3 large MD groups & 5 CHCs - service area Greater Boston, North Shore, Springfield Senior Whole Health: Independent network including Caritas Christi & other hospitals in eastern/central Mass.

SCO Progress Enrollments approaching 7700 High enrollment in underserved, diverse neighborhoods Aging industry participating in new SCO business SCOs continually expanding provider networks and service areas Contact: Diane Flanders, MassHealth Office of Long Term Care 617-222-7409 diane.flanders@state.ma.us