1. sco
Senior Care Options
Bringing Medicare
and MassHealth Together

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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)

10. 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

11. 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.

12. 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