New England Consortium: Massachusetts
MassHealth Senior Care Options

Project Overview

General Approach: A fully integrated managed care program, to be offered through Senior Care Organizations (or SCOs), covering the full range of acute and long-term care benefits for dually eligible and Medicaid-only recipients age 65 and over. Enrollment will be voluntary. Through an innovative partnership, the State and the Centers for Medicare and Medicaid Services (CMS) will jointly contract with SCOs.

Implementation Date: May 2003 (anticipated)

Waiver(s): Massachusetts originally submitted an 1115/222 waiver request. As a result of the Balanced Budget Act of 1997 (BBA), which was enacted after the State submitted its waiver request, the Medicaid authority for the initiative can now be achieved without a waiver of current law. Medicare 222 reimbursement waivers and variances of Medicare+Choice plan regulations are still required. Such Medicare waivers and variances will be granted by CMS to selected SCOs.

Eligible Population(s): Massachusetts and CMS aim to offer enrollment in SCOs statewide, assuming qualified SCOs bid for every area. Dually eligible seniors (65 years of age and older) and seniors eligible for Medicaid-only will be offered the option of joining a SCO.

Benefit Package: The SCO benefit package will include the full continuum of Medicare Part A and B services, and Massachusetts Medicaid covered services. In addition, SCOs may authorize and deliver alternative or "diversionary" services in lieu of more traditional acute and long term care services.

Delivery System: Through this initiative, Massachusetts and CMS wish to stimulate the entrance of new kinds of organizations into the healthcare marketplace. SCOs may be developed out of different configurations of provider networks. Since 1999, approximately thirty organizations have expressed interest in sponsoring a SCO, including hospital networks, long-term care management companies, community agencies, rehabilitation networks and Medicare+Choice plans.

Specifications: SCO bidders will have to demonstrate the ability to deliver or arrange for the delivery of the full continuum of Medicare and Medicaid covered services including primary, preventive, acute, specialty, mental health, substance abuse, and community and institutional long-term care services. SCO Purchasing Specifications detail the access, quality, and financial solvency standards which bidders must meet in order to qualify as SCOs. SCOs will be responsible for providing a selection of Primary Care Physicians, so that enrollees can chose who will coordinate their care. For enrollees with complex care needs, Primary Care Teams, consisting of a Primary Care Physician, a nurse, nurse practitioner or physician's assistant, and a Geriatric Support Services Coordinator (GSSC) will be responsible for arranging, integrating and delivering care.

SCOs will be required to contract with one or more Aging Services Access Points (ASAPs) designated by the Executive Office of Elder Affairs. (ASAP is the name used to refer to the Massachusetts's Aging Network.) ASAP employees will serve on Primary Care Teams as GSSCs.

Quality Assurance Activities: The State and CMS have developed an extensive quality monitoring process to assure that SCOs deliver state-of-the-art medical services. This performance-based contracting system, based on the concepts of Continuous Quality Improvement (CQI), shall include structural requirements assessed during the contract selection process, quality management processes internal and external to the SCO, and outcomes data measurement to identify areas requiring intervention.

For example, SCOs will be required to provide a medical director, a geriatrician and a mental health clinician with geriatric expertise who will be responsible for implementing the SCO's internal quality management program, establishing protocols and advising PCPs and other SCO providers. PCPs and other Primary Care Team members will need to demonstrate experience caring for seniors and completion of continuing education programs in geriatric practice. SCOs will also have to establish mechanisms for assessing provider performance with regard to utilization of services, Primary Care Team performance, enrollee satisfaction and access to care.

SCOs will be required to regularly report indicators of clinical and administrative performance to CMS and the State. For example, SCOs will report their performance relative to clinical indictors such as influenza and pneumonia vaccination rates and will implement initiatives to address the needs of enrollees with certain chronic conditions such as diabetes, congestive heart failure, chronic obstructive pulmonary disease, depression and dementia. Outcome measures will include, among others, hospitalization rates, nursing facility utilization rates and changes in functional status. SCOs will regularly report information regarding enrollee satisfaction and complaints and appeals filed. SCOs must demonstrate timely responsiveness to enrollee concerns.

Technical Assistance Activities: The State sponsored a series of six technical assistance workshops for clinical and administrative leadership of organizations considering bidding to be a SCO. Sessions focused on the federal-state partnership, establishing the interdisciplinary care team, the centralized enrollee record, performance reporting requirements, enrollee rights and responsibilities, and administration and finance.

Payment: The demonstration will have a phased capitation payment approach. The Phase I Medicare capitation payment will be based on a combination of the Medicare+Choice base rates and "Social HMO" risk adjusters according to age, gender, nursing home placement or clinical equivalency, and county. The Phase I Medicaid payment will be fully capitated with six rating categories -- three for nursing facility residents at different clinical acuity (case-mix) levels, one for community nursing home eligible enrollees, one for community enrollees with a diagnosis of Alzheimer's, dementia and/or chronic mental illness, and one for other enrollees residing in the community. SCOs will receive two payments, one from Medicare and one from Medicaid, with funds integrated at the level of the SCO.

For Phase II, CMS and the State intend to develop a more sophisticated Medicare risk adjuster and a complementary Medicaid payment methodology to be implemented by the 5th year of the demonstration.

Current Status

Enrollment: N/A; project not yet implemented.

Recent accomplishments: Massachusetts and CMS signed a Memorandum of Understanding in April 2000, which confirms the federal-state commitment to work in partnership to implement Senior Care Options.
State enabling legislation was passed July 31, 2002, as part of the FY 03 state budget.

Next Steps

Through the Senior Care Options project core team, the State and CMS are following a detailed work plan with implementation time lines for enrollment, procurement, systems, payment, operations, and outreach. The Robert Wood Johnson Foundation, through its Medicare/Medicaid Integration Project, has provided funding to the State to be used for grants to selected SCOs for start-up activities.

Massachusetts and CMS have developed a joint procurement document, and are preparing to go to bid in mid November 2002. Current projections are that enrollments in SCOs may begin approximately six months after the procurement is issued.

Contact Information

Diane Flanders
Director, Senior Care Options
Massachusetts Division of Medical Assistance
600 Washington Street, 5th Floor
Boston, MA 02111

(617) 210-5440 (voice)
(617) 210-5003 (fax)
e-mail: dflanders@nt.dma.state.ma.us
Website: http://www.state.ma.us/dma/providers/prov_IDX.htm