MassHealth Managed Care for Older Members and Members with Disabilities Lori Cavanaugh
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MassHealth Managed Care for Older Members and Members with Disabilities Lori Cavanaugh Director of Purchasing Strategy NASHP Annual Conference October 4, 2011
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MassHealth Managed Care for Older Members and Members with Disabilities Lori Cavanaugh Director of Purchasing Strategy NASHP Annual Conference October 4, 2011. MassHealth Managed Care. Program Overview Move toward Integrated Care Policy Goals Key Considerations. - PowerPoint PPT Presentation
Transcript of MassHealth Managed Care for Older Members and Members with Disabilities Lori Cavanaugh
MassHealth Managed Care for Older Members
and Members with Disabilities
Lori Cavanaugh
Director of Purchasing Strategy
NASHP Annual Conference
October 4, 2011
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MassHealth Managed Care
■ Program Overview
■ Move toward Integrated Care
■ Policy Goals
■ Key Considerations
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MassHealth Disabled and Older Members by Program
115,000
70,037
48,856
2,624
17,180
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
SCO PACE MCO PCCP FFS Disabled 21-64
Programs for Older MembersVoluntary Opt-in Enrollment
Dual eligible and Medicaid-only members
Integrates MassHealth, Medicare, other community services– capitation payments pooled at program level
■ Senior Care Options Program (2004)– 4 contracted SCOs– Age 65+, live in any setting (in the community or a facility)– 17k enrollees of ~140k members age 65+
■ Program for All-inclusive Care for the Elderly – PACE (1990)– 6 Programs, 17 PACE Centers
– Age 55+, nursing facility level of care, live in the community– 2,600 enrollees
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Programs for Disabled <65 Mandatory EnrollmentMedicaid Only (non-dual eligibles)Statewide coverage
■ MCO Program (1980s)– 5 contracted MCOs– Capitated program, including behavioral health, with FFS
wrap for certain services: dental, LTC, PCA and home-based services
– 49k Disabled members of 495k total members
■ Primary Care Clinician Plan– PCCM FFS program with capitated behavioral health
carve-out (1992)– 70k Disabled members of 328k total members
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Disabled <65 by Plan & Age
0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
MCO PCCP
5: >=60 years
4: 26-59 years
3: 21-25 years
2: 13-20 years
1: 0-12 years
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Disabled <65 Relative Costs
*Excludes expansion categories of assistance with more limited benefits
0%
10%
20%
30%
40%
50%
60%
70%
MCO PCCP
% of CY10Enrollment
% of CY10Total Cost
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Integrated Care for Dual Eligible Members 21-64
In development, partnering with stakeholders and CMS
Approximately 115,000 eligible members
Statewide coverage
Voluntary opt-out enrollment proposed
Integration of Medicare and MassHealth program and financing
Medicare, Medicaid, and expanded covered benefitsBH diversionary services. certain LTSS
Blended global payment
www.mass.gov/masshealth/duals
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Integrated Care - Policy Goals
■ Maintain members in their homes and communities by integrating all aspects of preventive, acute and long term care
■ Establish accountability for person-centered delivery, coordination, and management of quality service and supports
■ Enhance care management, use of care teams to improve the quality and efficiency of care
■ Improve the quality of/access to BH services and integration of BH and Medical services
■ Increase cultural competency; reduce racial/ethnic disparities
■ Ensure that spending is value-based and cost-effective; link quality outcomes and payment
■ Provide members with a variety of managed health plans and provider choices that satisfy members’ needs
1010
DemographicsUtilizationCosts
StratificationRisk AdjustmentCosts
BenefitsEnrollmentQuality
RatesAdmin Load Risk SharingSavings
Program Development
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Key Considerations■ Program Goals■ Stakeholder / Member Input■ Covered Benefits / Carve-outs■ Care Coordination ■ Capacity of Provider Community■ Network Management■ Enrollment Policy and Supports■ Procurement Strategy■ Rate Development / Risk Adjustment■ Reporting and Monitoring Performance
– Quality– Financial– Encounter Data
