The state and federal government have begun to experiment with special models of health care delivery for the "Dual Eligible" population - those eligible for both Medicare and MassHealth.
One does NOT need to be a dual eligible to qualify for this program. Seniors who have MassHealth Standard coverage, but do not have Medicare can choose a Senior Care Options (SCO) plan. Seniors who have MassHealth and Medicare (dual eligibles) can choose a Medicare Advantage Senior Care Options HMO SNP (Special Needs Plan).
No one is required to join Senior Care Options. Enrollment is voluntary.
Benefits
Combines MassHealth and Medicare (if one has both) into one benefit with one insurance card. All health care is covered, including emergency care, acute care, doctor and therapy visits, home care, and nursing home care.
In addition, other care not always covered as a part of healthcare is covered, including transportation, daycare, dental care, eye care, prescription drugs, and medical supplies and equipment.
Any services, equipment, or purchases that are a part of the approved care plan and are deemed necessary can be provided.
All specialist, hospital, nursing home, home care, pharmacy, and other services used in the care plan must be a part of the senior care organization’s network in order to be covered services.
Note on Medicare D: It is not necessary for SCO Plan members to sign up for Medicare Part D, as the SCO Plan they belong to provides coverage of all drugs and pharmacy services covered under Medicare Part D. If a SCO Plan member signs up for Medicare Part D, they will be disenrolled from the SCO Plan they are currently enrolled in. (Source: SCO provider FAQ)
Enrollment
To enroll, individuals need to have or be eligible for enrollment in Mass Health standard. They need to live in the geographic area served by the senior care organization they choose to join. They do not have to have Medicare. If they do have Medicare, they must maintain their current Medicare coverage. If they currently pay for Part B premium, they must continue to do so. They must agree to use only providers and services within their senior care organizations network and must choose a doctor from within the network as their primary care doctor. They must agree to work with their doctor to create a care plan and to abide by the care plan.
Sources and for More Information About SCOs
- Senior Care Options - Mass.gov page
- MGH Payer Grid - MGH contracts SharePoint (MGH Practice Support)
- (Additional source no longer available: Massresources.org)
- Also see our Elder page > Home Care Covered by Insurance and Other Sources > SCOs
Integrated Care Organizations provide patient-centered medical homes that integrate primary care and behavioral health services, care coordination, and clinical care management. MassHealth is piloting combining Medicare and Medicaid funding for Dual
Eligibles.
With combined funding, OneCare seeks to offer a broader menu of services that will better meet
the needs of the population in the most cost effective way.
MassHealth has assumed complete operational responsibility for the
care of this population - comparable to its responsibility for its
MassHealth-only membership - including the administration, management and
oversight of all Medicare-funded and Medicaid-funded services.
This model seeks to
significantly improve the alignment of financial incentives and improve provider
accountability by making a Global Payment (capitation) for all Medicare and Medicaid
services.
The demonstration project duration in the agreement signed in August 2012 is through December 31, 2016.
OneCare offers full dental coverage.
NOTE: MGH and most Partners HealthCare entities will NOT participate in OneCare for primary care. For hospital and specialty care they will participate with some of the plans. Patients who are auto-enrolled and who wish to continue to see their MGH PCP will need to opt-out of OneCare. More information: OneCare- Dual Eligibles Coverage Starting in October, MGH Community News, September 2013.
Eligible Enrollees
Dual eligibles age 21-64.
Medicare Advantage, PACE, and Independence at Home enrollees may participate if they disenroll from their existing plan.
Excluded beneficiaries include those:
with developmental disabilities
- with other comprehensive coverage,
- who are ICF/DD facility residents, and
who are § 1915(c) HCBS waiver participants
Enrollment Process
Eligible beneficiaries may voluntarily enroll or they will be automatically enrolled; they would need to actively opt out if they do not want to participate. Beneficiaries may opt out of the demonstration prior to passive enrollment and thereafter on a monthly basis. Note: due to the limited plan participation not all eligible beneficiaries will be auto-enrolled. Only those who live in communities
where there are at least two plan options: Hampden, Hampshire, Suffolk, & Worcester county residents, and only those who are the least medically complex will be auto-enrolled.
NOTE: MGH and most Partners HealthCare entities will NOT participate in OneCare for primary care. For hospital and specialty care they will participate with some of the plans. Patients who are auto-enrolled and who wish to continue to see their MGH PCP will need to opt-out of OneCare. More information: OneCare- Dual Eligibles Coverage Starting in October, MGH Community News, September 2013.
Beneficiary outreach began in May 2013, with July 2013 as the earliest effective date for voluntary enrollment, followed by two passive enrollment periods: initial notice sent in August 2013 for passive enrollment effective October 2013, and initial notice will be sent in November 2013 for passive enrollment effective January 2014.
Benefits
Includes all Medicare and Medicaid state plan services EXCEPT:
-
Medicare hospice
-
Medicaid mental health
-
Developmental Disabilities targeted case management services and
-
Mental health rehabilitation option services
Plans have discretion to offer flexible benefits as appropriate to beneficiary needs; adds supplemental diversionary behavioral health and community support services and expanded Medicaid state plan benefits.
The ICOs will offer care coordination to all enrollees through a care coordinator or clinical care manager for medical and behavioral health services. Care coordination will also be offered through an Independent Living and Long-Term Supports and Services (LTSS) coordinator contracted from a community based organization.
In addition to the requirement that they provide all Medicare and Medicaid services, ICOS must also cover supplemental benefitsncluding those listed below. Unfortunately, the MOU provides no standards for determining WHEN these services must be provided.
Supplemental Benefits:
- day services
- home care services
- respite care
- peer support/navigation
- care transitions assistance
- home modifications
- community health workers
- medication management
- transportation*
-
preventive, restorative and emergency dental benefits (see Dental comparison fact sheet)
-
PCA
-
DME
*Non-medical transportation is provided to enable the member to access community services, activities and resources in order to foster the member’s independence and support integration and full participation in his/her community. Non-emergency medical transportation (NEMT) provides transportation to medically-related services.
Continuity of Care
Beneficiaries must be allowed to maintain their current providers and service authorizations for 90 days or until the plan completes an initial assessment, whichever is longer.
In urgent or emergency situations, the ICO must reimburse an out-of-network
provider at the Medicare or Medicaid FFS rate applicable for the service. Beyond
the 90 day transition period, under certain defined circumstances, plans will be
required to offer an out-of-network agreement to providers who are currently
serving the enrollee and are willing to continue serving them.
Participating Plans
- Commonwealth Care Alliance
- Fallon Total Care
- and Network Health.
Ombudsman program- OneCare members can contact the Ombudsman with any questions or concerns by phone at 1-855-781-9898 or email at help@onecareombuds.org. The OneCare Ombudsman is hosted by Health Care for All, MA. Learn more.
Stakeholder Engagement
Plans must establish at least one consumer advisory committee that provides input to the governing board and include beneficiaries with disabilities in the plan governance structure
For More Information
Additional Sources and Info for Policy Wonks:
