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Integrated Care Programs Overview:One Care, PACE, and SCOExecutive Office of Health & Human ServicesMassHealth Office of Long-Term Services andSupports

Integrated Care ProgramsThree Integrated Care Programs: One Care PACE (Program of All-inclusive Care for the Elderly) SCO (Senior Care Options)Objectives of the Integrated Care Programs: Support members to stay in their homes and communities by integratingall aspects of preventive, acute, behavioral health, and long-term care Establish accountability for delivery, coordination, and management ofquality medical and behavioral health service and supports Integrate Medicaid and Medicare programming and financing2

One Care3

One Care ObjectivesOne Care Objectives: Providing a broad range of health care services, including medicalservices, behavioral health services, and long-term services and supportsthat support a member's ability to live independently in the community Creating a comprehensive, whole-person view of each individual’s goalsand needs, including how their environment presents barriers or supportsthem to live independently A capitated financial structure paid by Medicare and Medicaid tocontracted health plans that promotes innovation and flexibility in amember's care4

What is One Care?With One Care, individuals ages 21-64 whoare eligible for both MassHealth andMedicare (dual eligibles) to accesscomprehensive benefits and carecoordination through a single health plan5

What services are covered?Medicare: All Part A,Part B, and Part DservicesMedicaid State PlanServices- including Long-termServices and Supports(LTSS)Integrated toImprove Qualityand ReduceUnnecessaryCostsBehavioral HealthDiversionary ServicesAdditional Communitybased Services6

Who is Elig ible for One Care?Age 21-64uponenrollment**Notresiding inICF*Eligible forMassHealthStandard orCommonHealthNot enrolledin PACE,SCO, HCBSWaiverEnrolled inMedicare PartsA & B andEligible forMedicare Part DEnrolleesWithout othercomprehensiveinsurance*Intermediate Care Facility;** Members can remain in their One Care Plan after turning 65 if they maintain theirMassHealth Standard eligibility7

Delivery of Care Person-Centered Care Health care and services are based on the goals and preferences ofthe individual The One Care Enrollee Decides who will attend meetings and be involved in decisions Attends every meeting about their care Their goals and preferences play an integral role in decision-makingprocess All options are fully explored and discussed, and choice is respected Care delivered through Care Team and provider network Integration of primary care, specialists, behavioral health, and LTSS Person-centered assessment, planning, and service delivery usingmedical home or health home models as foundation8

One Care Plans and Service Areas* One Care plans are contracted jointly by MassHealth and Medicare Commonwealth Care Alliance rs/one-careBarnstable, Berkshire, Bristol, Essex, Franklin, Hampden,Hampshire, Middlesex, Norfolk, Plymouth, Suffolk and Worcestercounties Tufts Health Unify alth-unify/homeBristol, Middlesex, Norfolk, Plymouth, Suffolk and Worcestercounties UnitedHealthcare aid/one-careBristol, Essex (partial), Franklin, Hampden, Hampshire, Middlesex,Plymouth, Suffolk, and Worcester counties*Dukes and Nantucket are outside of One Care coverage areas9

How do you enroll for One Care?1. Enroll online* by visiting the One Care website andclicking on “How to enroll in One Care” –www.mass.gov/one-care2. Complete and mail or fax the paper One Care EnrollmentDecision Form (also available on the One Care website)3. Call the MassHealth Customer Service Center (Monday –Friday, 8:00 am – 5:00 pm) at 1-800- 841- 2900 or TTY:1-800-497-4648 (for people who are deaf, hardof hearing, or speech disabled)*The online form can be accessed at https://masshealth.ehs.state.ma.us/onecare/10

Senior Care Options (SCO)11

Senior Care Options (SCO) SCO Plans are comprehensive health plans that combine healthand social support services covered by Medicare and MassHealth.SCO provides services to members through a SCO Plan andits network of providers The SCO program began as a demonstration project in 2004,initially authorized by state legislation and through a Memorandumof Understanding with CMS SCO Plans are now Dually-Eligible Special Needs Plans (D-SNPs)a type of Medicare Advantage plan EOHHS and CMS share oversight of the program12

SCO Eligibility & EnrollmentTo enroll in SCO, a person must: Age 65 and over Be eligible for MassHealth Standard (can be eligiblefor MassHealth Standard through the Frail ElderWaiver) May or may not have Medicare (A and/or B) (I.e.members who only have MassHealth and notMedicare are eligible to enroll) Can live in any setting (in the community or a facility)*Enrollment is voluntary13

SCO Program StructureManaged Care Program All enrollees must select a Primary Care Physician (PCP) All enrollees must see providers in their SCO Plan'snetwork Capitation payment from MassHealth and CMS to the Plansis generally based on enrollee geography and on clinicalrating categoryIntegrates MassHealth, Medicare with other communityservices All MassHealth services, including comprehensivebehavioral health services and LTSS All Medicare services, including Part D Community services (1915c waiver services): Meals onWheels, Homemaker services, etc. Members have one card and providers bill the SCO14

SCO Plans and Service Areas* BMC HealthNet Plan Senior Whole Health Commonwealth CareAlliance Tufts Health Plan NaviCare Fallon Health United HealthcareBarnstable, Bristol, Hampden, Plymouth,Suffolk, WorcesterBristol, Essex, Franklin, Hampden, Hampshire,Middlesex, Norfolk, Plymouth, Suffolk,WorcesterBarnstable, Berkshire, Bristol, Essex, Franklin,Hampden, Hampshire, Middlesex, Norfolk,Plymouth, Suffolk, WorcesterBristol, Essex, Hampden, Middlesex, Norfolk,Plymouth, Suffolk, WorcesterBarnstable, Bristol, Essex, Hampden,Hampshire, Middlesex, Norfolk, Plymouth,Suffolk, WorcesterBristol, Essex, Hampden, Hampshire,Middlesex, Norfolk, Plymouth, Suffolk,Worcester*Dukes and Nantucket are outside of SCO Service Areas15

Benefits for SCO Enrollees Individualized care plan is developed for every enrollee Primary Care Team for members with complex care needs, including:PCP, Nurse Care Manager, Geriatric Social worker (from local ASAP) PCP/Team coordinate all the enrollee's services and provide access to24/7 Nurse Care Manager, utilizing Electronic Centralized EnrolleeRecord Enhanced Medicare, Medicaid, and supplemental benefits with nomember out of pocket cost (no copays) Electronic Centralized Enrollee Record - current, confidential, andavailable to care team 24/7 Access to full range of community supports through geriatric socialwork expertise from the Aging Service Access Points (ASAPs) Ease of administrative burden associated with traditional Medicare andMedicaid coordinated for the dual eligible population16

Program of All-inclusiveCare for the Elderly (PACE)17

Program of All-Inclusive Care for the Elderly(PACE) PACE is a fully capitated Medicare and Medicaid managedcare program authorized under federal regulation andmanaged jointly by MassHealth and CMS PACE is a community-based program that offers acomplete range of health and health-related servicesdesigned to keep frail elders living in the community safelyfor as long as possible PACE is a center-based model where participants visit theCenter for their care, or PACE staff coordinate care in anenrollee's home, rehab, etc.18

Program of All-Inclusive Care for the Elderly(PACE)PACE Facts: EOHHS and CMS share oversight of the program, withMassHealth responsible for:Contract monitoring and complianceEnrollmentPlan financials Capitation payment for PACE participants encompasses twocohorts (rate cells): 1.Medicare and MassHealth (Dual Eligible)2.MassHealth (Medicaid-only)19

Program of All-Inclusive Care for the Elderly(PACE)Eligibility: Age 55 and older At a nursing home level of care (i.e. nursing homecertifiable) Live in a PACE service area Able to live safely in the community at the time ofenrollment If a MassHealth member, eligibility must be Standard Meet the Title XVI disability standards if 55 through64 years of age20

Program of All-Inclusive Care for the Elderly(PACE)PACE ServicesPACE is a community-based program that offers acomplete range of health and health-related servicesdesigned to keep frail elders living in the communitysafely for as long as possible.Coordinated care is planned and provided by aninterdisciplinary team (IDT) of providers that includesphysicians, nurse practitioners, nurses, social workers,rehabilitation and recreation therapists, health aides,and others.21

Program of All-Inclusive Care for the Elderly(PACE)PACE Services cont.PACE works in partnership with each participant and theircaregivers to create an individually designed care plan tobest meet the needs of each personPACE delivers all needed medical and supportiveservices, including hospitalizations, rehabilitation services,and long-term care servicesMedical care is provided by a PACE physician familiarwith the history, needs, and preferences of eachparticipant22

Program of All-Inclusive Care for the Elderly(PACE) Enrollment is voluntary PACE participants must receive all services, except emergencyservices, from the PACE network of providers PACE providers are at full risk for all services received by theirparticipants from PACE PACE providers are paid a monthly capitation rate from bothMassHealth and Medicare Participants do not need to have Medicare or MedicaidConditions/Limitations Requires pre-admission screening completed and submitted bythe PACE via electronic MDS-HC to MassHealth PACE ClinicalCoordinator with final authorization from MassHealth to confirmmember is at a nursing home level of care/nursing homecertifiable23

Integrated Care ProgramsOne CareEligiblePopulationAge 21-64 at the Age 55 time of enrollment Eligible for Eligible forMassHealthMedicare andStandard,MassHealthMedicareStandard orand/or privateCommonHealthpay AvailablesinceEnrollmentPACE(Program of AllInclusive Care forthe Elderly)Disabled SCO(Senior CareOptions) Age 65 Eligible forMassHealthStandardNursing facilitylevel of care20131994200432,4694,74269,85424

Integrated Care ProgramsOne CareCareCoordinationthroughService DeliveryPACE(Program for AllInclusive Care forthe Elderly)One Care planPACE orgSCO planProvider networkCenter-basedmodelprovides servicesat the PACE siteand in thecommunityProvider networkMembercopaymentBenefitsSCO(Senior CareOptions) 0 Medicare Part A (hospital) Medicare Part B (outpatient) Medicare Part D (Rx) All MassHealth (LTSS, Dental, Vision, etc.)25

Integrated Care Programs PlansOne Care –3 plansSenior Care Options –6 plansNo coverage currently in Dukes, Nantucket countiesBarnstable, Berkshire,Bristol, Essex, Franklin,Hampden, Hampshire,Middlesex, Norfolk,Plymouth, Suffolk,WorcesterBristol, Essex, Hampden,Hampshire, Middlesex, Norfolk,Plymouth, Suffolk, WorcesterBristol, Essex, Hampden,Middlesex, Norfolk, Plymouth,Suffolk, WorcesterBristol, Essex, Franklin, Hampden,Hampshire, Middlesex, Norfolk,Plymouth, Suffolk, WorcesterBristol, Middlesex, Norfolk,Plymouth, Suffolk,WorcesterBristol, Essex (partial),Franklin, Hampden,Hampshire, Middlesex,Plymouth, Suffolk,WorcesterPACE –8 organizationsNo coverage currently inBarnstable, Berkshire, Dukes,Nantucket countiesCambridge Health Alliance,Middlesex, SuffolkElement Care,Essex, MiddlesexHarbor Health,Bristol, Middlesex, Norfolk,Plymouth, SuffolkMercy LIFE,Barnstable, Berkshire, Bristol,Essex, Franklin, Hampden,Hampshire, Middlesex, Norfolk,Plymouth, Suffolk, WorcesterBarnstable, Bristol, Essex,Hampden, Hampshire, Middlesex,Norfolk, Plymouth, Suffolk,WorcesterBarnstable, Bristol, Hampden,Plymouth, Suffolk, WorcesterHampden, HampshireNeighborhood PACE,Middlesex, SuffolkSerenity,Franklin, Hampden, HampshireSummit/Fallon,Essex, Hampden, Hampshire,Middlesex, WorcesterUpham’s,Norfolk, Suffolk26