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

2. 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

3. One Care Target Population
Target population is 111,000 dual eligibles ages 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. Integration Successes and Challenges13 13 13

14. 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

15. 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 = 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 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
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 : MA Duals RFR Responses to Bidders Question 8/12

16. 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
> % = 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

17. 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

18. 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

19. Status Update and Implementation Focus Areas19 19 19

20. 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

21. 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

22. Visit us at www.mass.gov/masshealth/onecare
us at