Mass. Councils on Aging PresentationOctober 2013

Health insurance plan combines Medicare and Medicaid payments and services, like a Senior Care Organization (SCO) but with additional features

Person-centered model providing the full range of acute, behavioral health, and long term supports and services

Designed to coordinate care and provide higher quality, more cost-effective care with improved health outcomes

Full Medicare and MassHealth beneficiaries 21-64 years old in service area

Approximately 90,000 dual eligible beneficiaries with some exclusions, such as:

◦ MassHealth Members enrolled in Home and Community-based Services waivers-- Frail Elder, Traumatic Brain Injury, Acquired Brain Injury, Developmental Disability and Money Follow the Person waivers

◦ Residents of ICF/ID- Intermediate Care Facility for Intellectually Disabled

Note: at age 65, beneficiary may remain in the One Care Plan if he/she still meets MassHealth eligibility guidelines

All Medicare and MassHealth benefits are guaranteed

All medically necessary services including inpatient hospital, community health center, DME (durable medical equipment), home health, day habilitation

Expanded benefits like Care Coordination, dental, personal care (PCA), DME training, adaptive technology, vision services, non-medical transportation

Behavioral health care such as inpatient mental heath and substance abuse, community crisis stabilization, psychiatric day, outpatient therapy, case and family consultation, acupuncture, coaching, peer support

A beneficiary who needs additional services such as long term community supports or behavioral health

A beneficiary who has found services to be fragmented and uncoordinated

A beneficiary who has had difficulty accessing services for variety of reasons

A One Care plan must Contract with community based organizations –Independent Living Centers, ASAPS, Recovery Learning Communities, other organizations serving people with disabilities

Promote independent living by using community health workers, qualified peer specialist, non-medical staff, housing specialist for the homeless

Attempt smooth transition of current provider services by obtaining numerous provider contracts and offer individual contracts if feasible

A One Care Plan must Ensure staff and providers are culturally competent and trained in values, beliefs associated with a beneficiary’s age, gender, racial, ethnic, linguistic background

Reasonably accommodate persons and ensure accessibility in scheduling

Provide interpreters or translators, accessible communication

Ensure safe and appropriate physical access

Provide referrals to independent living and recovery, home based services as needed

Initial voluntary enrollment opportunity in September

Three phases of auto-assignment◦ January 1, April 1, July1 members who have not made a decision

At any time a beneficiary may opt in, opt out, or change from one plan to another

Enrollment changes are effective first day of the following month

During 90-day period after enrollment, the One Care plan and enrollee engage in a comprehensive assessment and care planning process

Enrollee’s current services and providers stay in place until care planning process is complete and enrollee agrees to the new plan.

MassHealth/CMS will send information in advance of initial enrollment and 60 days before any auto enrollment periods

At the same time, plans will be allowed to market

Letter will direct calls to MassHealth and SHINE regional offices at1-800-243-4636

Information about One Care plans will be on www.mass.gov/masshealth/onecare, www.medicare.gov and provider lists will be accessible on provider sites

To enroll call MassHealth at 1-800-841-2900

The person-centered care plan and package of services will be developed by the One Care plans during meetings with individual, caregiver, family, care coordinator, health care staff and Independent Living – Long Term Services and Supports (IL-LTSS) coordinator. Grievances will be filed internally.

Appeals are made through MassHealth or Medicare

An independent Ombudsperson role will be developed advocate for consumers and to impartially resolve disagreements, problems with service plan, denials of service

Counselors will Assist eligible beneficiary to understand what One Care is and review choices: join One Care plan, choose among plans, or opt out of One Care and continue to receive current services

Search medicare.gov for plan comparisons and review available provider lists to ensure continuity of careComplete client contact form including new data fields as required by CMS

Provide beneficiaries with relevant information and assist with enrollment processBe culturally competent and ensure accommodation as needed

Three companies offer One Care plans in select counties. All have significant experience with Medicaid and similar models of care:

Commonwealth Care Alliance Contact: 1-866-610-2273, www.commonwealthonecare.org

Fallon Total Care Contact: 1-800-879-0852, www.fallontotalcare.org

Network Health Contact: 1-855-393-3154, www.ChooseUnify.com

County CCA Fallon Network Health

#members can enroll

#members no plan

Essex x 13,452

Franklin x 1,945

Hampden x x 13,981

Hampshire x x 2,452

Middlesex x 16,856

Norfolk x 6,760

Plymouth x* 6,208 723

Suffolk x x 14,664

Worcester x x x 13,922

Total state 90,240 20,933(Barnstable,Berkshire, Bristol, Dukes,Nantucket,partial Plymouth

SHINE 1-800-243-4636, press 3

MassHealth Customer Service 1-800-841-2900 TTY:1-800-497-4648

www.mass.gov/masshealth/onecare

One Care Plan web sites