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
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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
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