MassHealth Managed Care for Older Members and Members with Disabilities Lori Cavanaugh Director of Purchasing Strategy NASHP Annual Conference October 4, 2011

2 MassHealth Managed Care ■Program Overview ■Move toward Integrated Care ■Policy Goals ■Key Considerations

3 MassHealth Disabled and Older Members by Program

Programs for Older Members Voluntary Opt-in Enrollment Dual eligible and Medicaid-only members Integrates MassHealth, Medicare, other community services –capitation payments pooled at program level ■Senior Care Options Program (2004) –4 contracted SCOs –Age 65+, live in any setting (in the community or a facility) –17k enrollees of ~140k members age 65+ ■Program for All-inclusive Care for the Elderly – PACE (1990) –6 Programs, 17 PACE Centers –Age 55+, nursing facility level of care, live in the community –2,600 enrollees 4

5 Programs for Disabled <65 Mandatory Enrollment Medicaid Only (non-dual eligibles) Statewide coverage ■MCO Program (1980s) –5 contracted MCOs –Capitated program, including behavioral health, with FFS wrap for certain services: dental, LTC, PCA and home-based services –49k Disabled members of 495k total members ■Primary Care Clinician Plan –PCCM FFS program with capitated behavioral health carve-out (1992) –70k Disabled members of 328k total members

6 Disabled <65 by Plan & Age

7 Disabled <65 Relative Costs *Excludes expansion categories of assistance with more limited benefits

8 Integrated Care for Dual Eligible Members  In development, partnering with stakeholders and CMS  Approximately 115,000 eligible members  Statewide coverage  Voluntary opt-out enrollment proposed  Integration of Medicare and MassHealth program and financing  Medicare, Medicaid, and expanded covered benefits BH diversionary services. certain LTSS  Blended global payment

9 Integrated Care - Policy Goals ■Maintain members in their homes and communities by integrating all aspects of preventive, acute and long term care ■Establish accountability for person-centered delivery, coordination, and management of quality service and supports ■Enhance care management, use of care teams to improve the quality and efficiency of care ■Improve the quality of/access to BH services and integration of BH and Medical services ■Increase cultural competency; reduce racial/ethnic disparities ■Ensure that spending is value-based and cost-effective; link quality outcomes and payment ■Provide members with a variety of managed health plans and provider choices that satisfy members’ needs

10 Data Global Payments Data Program Design Policy Goals Demographics Utilization Costs Stratification Risk Adjustment Costs Benefits Enrollment Quality Rates Admin Load Risk Sharing Savings Program Development

11 Key Considerations ■Program Goals ■Stakeholder / Member Input ■Covered Benefits / Carve-outs ■Care Coordination ■Capacity of Provider Community ■Network Management ■Enrollment Policy and Supports ■Procurement Strategy ■Rate Development / Risk Adjustment ■Reporting and Monitoring Performance –Quality –Financial –Encounter Data

Contact information: 12