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Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared – Appendix – Massachusetts – 8426-06 « » The Henry J. Kaiser Family Foundation

Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared: States with Memoranda of Understanding Approved by CMS


MOU Signed: Aug. 22, 2012;
3-way contract signed July 16, 20131(initial term through Dec. 31, 2014)
Demonstration Duration: 3 years
Oct. 1, 20132 to Dec. 31, 2016
Target Group:
Includes:  an estimated 90,240 full benefit dual eligible beneficiaries ages 21 to 64 in 8 full counties and 1 partial county3 are eligible to enroll; Medicare Advantage, PACE, and Independence at Home enrollees may participate if they disenroll from their existing plan
Excludes: dual eligible beneficiaries with other comprehensive coverage, ICF/DD facility residents, and § 1915(c) HCBS waiver participants
Geographic Area: 9 counties:  Essex, Franklin, Hampden, Hampshire, Middlesex, Norfolk, Plymouth (partial), Suffolk, Worcester
Initial enrollment period is voluntary, followed by passive enrollment periods in which the remaining beneficiaries in the target population will be automatically enrolled except that no passive enrollment will take place in counties served by only one demonstration health plan (Essex, Franklin, Middlesex, Norfolk, Plymouth)
Beneficiary outreach began in September 2013, with October 2013 as the earliest effective date for voluntary enrollment, followed by passive enrollment in Hampden, Hampshire, Suffolk, and Worcester counties (total 45,019 beneficiaries subject to auto-assignment):4  initial notice sent in Oct. 2013 for first passive group (an estimated 8,600 beneficiaries in community-other rating category) with enrollment effective January 2014.5  As of Feb. 1, 2014, 9,541 beneficiaries were enrolled, and 16,642 beneficiaries had opted out of the demonstration.6  The effective enrollment date for the second passive enrollment group is April 2014 (an estimated 6,400 beneficiaries in the high community need, high community behavioral health, and community-other rating categories) and July 2014 for the third passive group.7  Beneficiaries receive notices 60 and 30 days prior to passive enrollment.
Beneficiaries may opt out of the demonstration prior to passive enrollment and thereafter on a monthly basis
Massachusetts is using § 1915(a) authority to enroll dual eligible beneficiaries in Medicaid managed care.
Intelligent assignment for passive enrollment will prioritize continuity of providers and/or services
Financing: Capitated with savings percentage (0 in 2013, 1% in 2014 (remainder of year one),8 2% in year two, and >4% in year three9) applied upfront to baseline Medicare and Medicaid contributions; capitation rate quality withhold same as in California(1% in year 1, 2% in year 2, 3% in year 3)
Medicare baseline for capitated payments: Same as California
Medicare risk adjustment: Same as California
Medicaid baseline for capitated payments: Historical state spending data trended forward
Medicaid risk adjustment: Rating categories10 and high cost risk pools for certain Medicaid LTSS11
Risk sharing: Risk corridors in first year only12
Care Delivery Model:
One Care plans will provide patient-centered medical homes that integrate primary care and behavioral health services, care coordination, and clinical care management
Requires Long-Term Supports Coordinators from community-based organizations independent of health plans as members of the care team
Participating Health Plans:
-Essex. Franklin, Middlesex, Norfolk, and Plymouth (partial) counties:  Commonwealth Care Alliance
-Hampden and Hampshire counties:  Commonwealth Care Alliance and Fallon Total Care/Fallon Community Health Plan
-Suffolk County:  Commonwealth Care Alliance and Network Health/Tufts Health Plan
-Worcester County:  Commonwealth Care Alliance, Fallon Total Care/Fallon Community Health Plan, and Network Health/Tufts Health Plan
Benefits: Includes all Medicare and Medicaid state plan services except Medicare hospice and Medicaid mental health and DD 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 (including additional dental services)13
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
Ombuds Program: Massachusetts selected Disability Policy Consortium (to be supported by Health Care for All and Consumer Quality Initiatives) as its demonstration ombudsman;14 not addressed in MOU
Stakeholder Engagement: Same as California
Notice:  same as California (single integrated notice)
Timeframe to request initial appeal:  same as Illinois (60 days)
Internal health plan appeal:  same as Illinois (all initial appeals must be filed with health plan) except that appeals are to be resolved in 30 days (standard) or 72 hours (expedited)
External Medicare appeals:  same as California (health plan automatically sends appeal to Medicare IRE if initial denial upheld; beneficiary may then request Office of Medicare Hearing and Appeals review
External Medicaid appeals:  beneficiary may request fair hearing after adverse health plan appeal
Appeals where Medicare and Medicaid services overlap:  to be addressed in 3-way contract; health plan bound by decision most favorable to beneficiary
Continued benefits pending appeal:  health plans must provide continuing benefits for all prior approved Medicare Parts A and B and Medicaid services while health plan appeals are pending; beneficiaries may request continuation of previously authorized services for Medicaid appeals while fair hearings are pending
Medicare Part D:  same as California (existing Medicare Part D appeals process continues)


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