Commonwealth Care Commonwealth Care / MMCO Key Contract Terms – Contract Year 2009

2 Summary In December, 2007, the Connector began a bid process to establish the capitation rates for FY 2009 In addition to new capitation rates and risk sharing provisions, staff negotiated a number of language revisions to the current contract This was the first comprehensive bid process since initial bidding in Sept. 2006

3 Key Contractual Goals Ensure continued development of strong care and utilization management programs Strengthen program integrity Simplify plan type choices to meet the needs of enrollees Continue to refine program to be more commercial-like, especially at higher income levels –Open enrollment process and member choice

4 FY09 Specific Contract Changes Provision for a full contract review and a claims and care management audit Provision regarding exclusivity arrangements between MMCOs and Providers MMCOs must make best efforts to provide member orientation to the health plan and to encourage the completion of an HRA (Health Risk Assessment)

5 FY09 Specific Contract Changes (continued) Interim sanctions for a contract breach –Allows Connector to impose penalties, including financial, that are less severe than contract termination Elimination of Plan Type IV (the lower co- pay/higher premium option available to members > % of poverty) Newly agreed-upon capitation rates and risk-sharing provisions previously discussed with the Board

6 FY09 Specific Contract Changes Quarterly interim settlement provision for Plan Type I only Co-pay accumulator must be implemented by July 1, 2008 Allows health plan to track co-pays across services (pharmacy and all others) for the purpose of calculating Member Out-of- Pocket Maximums DoI-approved licensure requirements with specific timelines identified

Commonwealth Care Open Enrollment April 2008

8 Open Enrollment About to embark on first open enrollment where members will be experiencing a change in their premiums due to bid process During open enrollment (and for a lengthy period after that time) members can change their plan for any reason Extensive information and support will be provided to members to facilitate this process

9 Lowest Cost Commonwealth Care Health Plan SFY09 Annual Gross Income RangeLowest Cost Plan* Starting PointEnd Point (FPL%)FY08FY09 Change from 2008 $0$15,612 (150%)$0 $15,613$20,808 (200%)$35$39+$4 $20,809$26,016 (250%)$70$77+$7 $26,017$31,212 (300%)$105$116+$11 * If member chooses a health plan other than the lowest cost plan they will pay: - Incomes 100 – 150%: 50% of cost difference (for FY09 only) - Incomes above 150% FPL: 100% of cost difference

10 Enrollee Contributions Premium-paying members will have a range of experiences –Based on current MCO, plan type and service area, there will be decreases as well as increases Based on premium paying member’s plan selection as of March 1, 2008: –34% of members will see no change –18% will pay less –22% will pay less than $5.00 more –15% will pay less than $50.00 more –11% will pay more than $50.00

11 Implementation Staff are working very closely with the plans and vendors to ensure a smooth transition Focused on two key areas: –Network Capacity (PCPs & Specialists) –Ensuring continuity of coverage & care –Working with plans on how to best manage possible continuity of care issues

12 Open Enrollment 2008 May 1 – June 13 Any Commonwealth Care member who lives in an area that offers more than one health plan can change their health plan for any reason by: –Completing the Open Enrollment Health Plan Change Request form or –Calling the Commonwealth Care Customer Service Center (1-877-MA-ENROL)

13 Open Enrollment Materials Each premium-paying member will receive a –Letter explaining the process –Notice of the co-pay changes –A form with their plan options (and costs) –Comparison grid for the plans in their area

14 Methods of Communication Invoice Messaging beginning 3/31 MCO Mailings - weeks of 4/21 and 4/28 Open Enrollment Packets – week of 4/28 Website 4/11 –Open enrollment page s 4/11 –‘Blasting’ to CommCare distribution list April Presentations –Staff will be going statewide to discuss the program changes and member options

15 Member Support Call Center is adding additional staff both in Boston and the overflow center Specific call scripts are being drafted that focus on –Helping the PT4s transition to PT3 –Explaining why there are cost differentials between plans –Guidance understanding the cost changes (co- pays and enrollee contribution)

16 Member Support Members in PT2A who fail to pay their premiums will be disenrolled to the lowest cost plan in their region Plan Type 4 conversions –No action required by the member unless they want to change their health plan –If no action is taken, member will automatically transition to the same health plan in PT3

17 Member Support con’t Members will also be allowed an additional 60 days (July and August) to change plans –Implementing this one-time process to facilitate changes and support members –Provides members the opportunity to stay with their existing provider should they want to complete a course of treatment –Will be developing the specifics around the process over the next few weeks

18 Plan Management Will be watching outcomes of open enrollment closely Working with plans on resolution of issues (and will make sure they don’t become systematic) Contract language will support changes –Access, wait times, ratios –Supports existing network expansion (in those areas where appropriate) –Stop exclusive provider contracts

19 Caseload Activity We have completed the second month of redetermination closings –Starting to analyze the data from this initial group –Experience is similar to the prior months