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Managed LTSS Program

The Massachusetts Senior Care Options program operates under Medicaid §1915(a) and §1915(c) authorities and provides services at a capitated rate to eligible adults age 65 and older. Enrollment is voluntary and available in most areas of the state. Services include primary, acute and behavioral health care; prescription drugs; and LTSS. LTSS services include nursing facility care; adult foster care; group adult foster care; adult day health; and other community-based LTSS. (Source: CMS and Truven Health Analytics, 7/2012)
State Website on Senior Care Options

Massachusetts House Speaker Robert DeLeo announced plans to create a study committee, made up of seven House members and six members from the health care sector, to examine Medicaid managed care organizations (MCOs) that have recently struggled financially. The fiscal issues are largely thought to be linked to lower-than-expected reimbursement rates. (Source: Boston Globe, 6/10/2015, link no longer available)

A recent report on Massachusetts’ Medicaid program, MassHealth, revealed that MassHealth had potentially spent $521 million dollars in duplicative payments. The report also cited network adequacy issues, and a failure to take advantage of cost saving measures within MCOs. (Source: Modern Healthcare, 6/17/2015)

On June 15, 2016, the Executive Office of Health and Human Services (EOHHS) of the Commonwealth of Massachusetts released an initial Section 1115 Demonstration Project Amendment and Extension Request for public comment, which was open through July 17, 2016. MassHealth, the state’s Medicaid and CHIP program, currently has a Section 1115 waiver through June 30, 2019, but a critical component called the Safety Net Care Pool (SNCP) expires on June 30, 2017. SNCP contains major federal investments, including payments through Delivery System Transformation Initiatives and Capacity Building grants. Therefore, EOHHS is requesting from the Centers for Medicare and Medicaid Services (CMS) that it be allowed to begin a full five-year extension of the entire program starting on July 1, 2017, which seeks to include up to $1.8 billion in Delivery System Reform Incentive Program (DSRIP) payments over the five-year period to support transitions into accountable care models.

The draft demonstration has five major goals:

  • Implement payment and delivery system reforms to better coordinate care and increase accountability;
  • Better integrate physical health, behavioral health, long term services and supports (LTSS), and other social services;
  • Maintain near-universal health insurance coverage;
  • Support safety net providers that care for Medicaid and other low-income individuals; and
  • Expand access to substance use disorder services in order to address the opioid crisis.

To achieve these goals, EOHHS is placing a major focus on transitioning from fee-for-service (FFS) to better integrated and accountable care. The new demonstration will allow providers the ability to form accountable care organizations (ACOs) through three different, innovative models:

  • Model A: ACO/MCO: is a partnership where a provider-led ACO is also a health plan.
  • Model B: ACO: is when a provider-led organization will contract directly with MassHealth to deliver coordinated care, but have the ability to offer preferred provider networks.
  • Model C: ACO: is a provider-led ACO that contract with MassHealth MCOs, and shares in savings or losses with the MCOs.

In  addition to these reforms under the new demonstration, and following a re-procurement, MCOs will take on additional responsibility for the delivery and coordination of LTSS. MCOs will follow the model of Massachusetts’s dual eligible demonstration—One Care—which coordinates care for beneficiaries jointly eligible for Medicare and Medicaid, and emphasizes person-centered care, community LTSS,  and independent living. (Source:  1115 Draft Application 6/15/2016)  

On November 4, 2016, the Centers for Medicare and Medicaid Services (CMS) formally approved Massachusetts request to extend the state’s Section 1115 waiver through June 30, 2022. The provisions of the waiver, which were outlined in the August 2016 edition of the State Medicaid Integration Tracker©, include additional Delivery System Reform Incentive Payments (DSRIP), implementation of three innovative Accountable Care Organization (ACO) models, and better integration of LTSS services. (Source: CMS Approval Letter 11/4/2016; August 2016 Tracker  8/24/2016)    

On December 21, 2016, the Massachusetts Executive Office of Health and Human Services (EOHHS) released a request for responses (RFR) from MCOs interested in serving the state’s Medicaid program, MassHealth. 1.3 million of the 1.8 million MassHealth beneficiaries are enrolled in one of four managed care programs, including the Primary Care Clinician (PCC) Plan, the MassHealth MCO Program, the OneCare program (which is the state’s dual eligible demonstration), and the Senior Care Options (SCO) program. This RFR only pertains to the MassHealth MCO Program enrollees, which number approximately 850,000.

The RFR makes two important departures from current MCO contracts. First, MCOs will be responsible for new requirements concerning implementation of the Medicaid ACO models that are a part of the state’s recently-approved section 1115 waiver. Second, Massachusetts aims to carve-in LTSS benefits for MassHealth MCO Program beneficiaries by 2020. Health Management Associates (HMA) estimates this may result in between $900 million and $1.3 billion in managed LTSS spending annually. 

Proposals for the RFR are due March 15, 2017. The anticipated implementation date for the new contracts is December 19, 2017. (Source: RFR 12/21/2016; HMA Weekly Roundup1/4/2017) 

On August 17, 2017, MassHealth, Massachusetts’ Medicaid program, announced it has contracted with 17 healthcare organizations to serve as Accountable Care Organizations (ACOs) under the state’s Medicaid redesign via a section 1115 waiver. On August 28, 2017, Massachusetts also announced the selection of 26 Community Partners to begin contract negotiations as a part of the implementation of the MassHealth ACO program. These community-based organizations will partner with ACOs to integrate and coordinate care for roughly 60,000 MassHealth members that have LTSS and/or behavioral health needs. Eight partners were selected for LTSS, and 18 were selected for behavioral health. Up to $145 million over a five-year period is available for the eight organizations selected as a LTSS Community Partner. (Source: ACO Announcement 8/17/2017; Community Partner Announcement 8/28/2017) 

On October 3, 2017, MassHealth announced it has awarded contracts with two MCOs, Boston Medical Center Health Plan and Tufts Health Public Plans, to care for nearly 200,000 Medicaid recipients. The contracts are valued at $1 billion a year, and run through 2020. The MCOs will be responsible for managing primary, behavioral, pharmacy and specialty care. Eligible members with complex behavioral health or LTSS needs will also be able to receive care coordination from Community Partners. (Source: MassHealth Release 10/3/2017) 

On October 17, 2017, WBUR reported on a multifaceted health care bill introduced in the Massachusetts State Senate. The bill seeks additional savings from MassHealth, the state’s Medicaid program, and also broader changes to the state’s health care system. Included in the bill are provisions targeted at some specific reforms to one of Massachusetts’ MLTSS programs, the Senior Care Options (SCO) program. Specifically, section 128 of the bill would:

  • Instruct the Massachusetts Executive Office of Health and Human Services to seek a federal waiver to allow for passive enrollment of dual eligibles (under the age of 55) into the program; 
  • Allow EOHHS to seek an additional waiver that would let Medicare beneficiaries who do not meet current Medicaid financial elgibility but do not have adequate income or assets to pay for 135 days in a skilled nursing facility (SNF) to prospectively enter the SCO program utilizing Medicare or alternative funding; and 
  • Obtain federal medical assitance percentage (FMAP) for Medicare beneficiaries enrolled in the Executive Office of Elder Affairs home care program who are not yet eligible for Medicaid but have insufficient income or assets to pay for 135 days in a SNF. 

The bill’s sponsor estimates that the overall proposed changes could save MassHealth $114 million for fiscal year 2020; more near-term savings would depend on when the reforms are implemented. (Source: WBUR 10/17/2017; Senate Bill)

On November 10, 2017, WBUR reported that the Massachusetts Senate passed a significant health care bill aimed at a variety of reforms for both the state’s Medicaid program and the commercial market. The bill retained proposed changes to the state’s Senior Care Options program—one of the state’s MLTSS programs—that were detailed in the November edition of the State Medicaid Integration Tracker©. The new version of the bill added specificity around opt-out procedures and protections for beneficiaries. (Source: WBUR 11/10/2017; Senate Bill)

LTSS Program

On February 23, 2016, Sentinel & Enterprise News reported on new measures from the Massachusetts to increase state oversight of LTSS programs, which account for approximately $4.5 billion of the state’s $15.4 billion Medicaid budget. Beginning March 1, 2016, the state will require prior approval for Medicaid LTSS expenditures, as well as establishing a conflict-free assessment for Medicaid patients. (Source: Sentinel & Enterprise 2/23/2016

State Demonstration to Integrate Care for Dual Eligible Individuals

In August 2012, CMS and Massachusetts signed a Memorandum of Understanding for the state’s One Care capitated demonstration model. The demonstration requires a three-way contract between CMS, the state, and an integrated care organization in order to oversee the care of 110,000 dual eligibles. The demonstration will cover dual eligible age 21-64, carving in acute and behavioural health for I/DD populations and carving out ICF/MR services; HCBS services for persons with DD; and HCBS services for persons with TBI. (Source: CMS website; Truven Health Analytics, 7/2012; NASDDDS Managed Care Tracking Report)
Duals Demonstration Proposal (2/16/2012)

The state later postponed its demonstration implementation date from April 2013 to July 2013. (Source: CMS Press Release, 8/23/2012; Financial Alignment Demonstrations for Dual Eligible Beneficiaries Compared: California, Illinois, Massachusetts, Ohio, and Washington, Kaiser Commission on Medicaid and the Uninsured, 5/2013)
Memorandum of Understanding
State Duals Demonstration website
Duals Demonstration Timeline
Three-Way Contract for Demonstration (7/11/2013)

The state also updated its demonstration implementation timeline with new effective dates for three waves of auto-assignment: January 1, 2014; April 1, 2014; and July 1, 2014. (Source: State HHS website)
One Care Implementation Council Work Plan (4/18/2014)

On July 25, 2014, MassHealth announced it has cancelled the October 2014 round of OneCare passive enrollment to give participating plans and the state more time to assess the quality of care and services being provided to enrollees.  (Source:  Community Catalyst, 8/20/2014; State OneCare Implementation Council website)

In October 2014, the Massachusetts Executive Office of Health and Human Services released its OneCare October Enrollment Report.  As of October 1, 2014, the total number of enrollees in the OneCare duals demonstration program is 17,465.  The total number that has opted out of the demonstration is 25,840.  While the planned October 2014 passive enrollment has been canceled, MassHealth and CMS will look into plans’ capacities to accept passive enrollees in 2015.  (Source:  Community Catalyst State Highlights, 10/1/2014; OneCare October Enrollment Report, 10/2014)

Fallon Community Health Plan will cease participating in Massachusetts state demonstration for dual eligibles, One Care, effective September 30, 2015. Fallon is the second most popular plan in the demonstration, serving 5,500 enrollees. (Source: Health IT Caucus, 6/19/2015)

On September 24, 2015, the Worcester Business Journal Online reported two new updates to the Massachusetts duals demonstration, or One Care. First, MassHealth has requested a two-year extension of the program that would expire in 2018. Second, the state intends to infuse the program with an additional $47.6 million dollars in combined state and federal funding over the next two years. (Source: WBJournal 9/24/2015)

MassHealth—Massachusetts’ Medicaid program—released a request for letters of intent (LOI) for dual eligible plans interested in offering plans for the state’s dual eligible demonstration, One Care. LOIs were due by August 1, 2016, and are non-binding. Tentatively, bids are expected to be due by November 2016, with enrollment effective as of January 1, 2018. (Source: Commbuys 7/7/2016)

OneCare and SCO Combined in Dual Demonstration 2: The complex needs of Medicare-Medicaid dual-eligibles in Massachusetts have been served by integrated care plans offered by One Care (a 1115A Duals Demonstration for individuals who are 21-64 years old at time of enrollment and living with disabilities) and SCO (Senior Care Options--a Fully Integrated Dual Eligible Special Needs Plan for individual ages 65 and over). MassHealth seeks to move One Care and SCO to a combined “Duals Demonstration 2”--a new aligned 1115A Demonstration--while maintaining the distinct population focus, service package, eligibility, and competency requirements of the current programs. The goals of this newly combined demonstration include increased access to integrated care, improved member outcomes, and financial sustainability for MassHealth, CMS, participating plans, and providers through value-based purchasing, increased transparency, data-sharing, and aligning administrative processes. This would include allowing Medicare Advantage bidding applicable for Parts A, B, and D, for One Care beneficiaries and creating a “high-utilizer” stop loss mechanism. (Source: Commonwealth of Massachusetts-Duals Demonstration 2.0 Draft Document, June 2018)


Medicare-Medicaid Demonstration Year 3 Plan Analysis:

Massachusetts Demonstration Year 3 (Year 2016) for Massachusetts’ One Care program included two providers—Commonwealth Care Alliance and Tufts Health Public Plans. An additional provider from 2015, Fallon Total Care, was no longer evaluated in the demonstration.  All Financial Alignment Demonstrations include a provision to ‘withhold’ a portion of the Medicare-Medicaid Plans’ capitation rate that can be recaptured if the MMPs meet quality measures.  In 2016, the two plans averaged 81% of performance measures met. The average percent of withholding “received” was 88%, with one plan receiving 100% and the other receiving 75% in 2016. (Source: MA Medicare-Medicaid Plan Demo Year 3, MA Year 2, 6-21-2018)

Medicare-Medicaid Coordination Initiatives
Changes in the Massachusetts Three-Way Contract, which was re-executed on June 11, 2018 included:
• Date extension to December 31, 2019.
• Technical corrections to the quality withhold measures.
• Specification of 2019 financial parameters

Balancing Incentive Program

In January 2014, Massachusetts submitted to CMS a BIP application. As of May 2014, CMS has approved the state’s BIP application. (Source: Kaiser BIP website; CMS BIP website)
Approved BIP Application (link no longer available)
BIP Structural Change Work Plan (9/25/2014 link no longer available)